Tennessee LTSS Workforce Quality Improvement Survey 2022

The Institute on Community Integration (ICI) at the University of Minnesota worked in collaboration with Amerigroup, UnitedHealthcare, and BlueCare TN, and TennCare to develop and administer the Quality Improvement in Long Term Services and Supports Workforce Initiative 2022 Survey, analyze the data, and report the results.

This survey is a continuation of TennCare’s quality improvement efforts in long term services and support that included a collaboration between TennCare, Tennessee Community Organizations (TNCO) and ICI to address workforce challenges for direct support professionals (DSPs) in Tennessee. This annual workforce survey has been a key component of a comprehensive workforce strategy in TennCare’s Quality Improvement in Long-Term Services and Supports (QuILTSS) Initiative. As part of this comprehensive effort, data gathered and reported from the first three years of the survey are informing ongoing discussions and planning about wages, benefits, and ways to recruit and retain good employees and enhance access to home and community-based services (HCBS) for people with intellectual and developmental disabilities in Tennessee. In the first three years of this initiative, organizations completing the annual workforce survey received a data summary about the direct support workforce in their organization. Participating organizations also have had the opportunity to take advantage of training and technical assistance from ICI workforce consultants and TN workforce coaches to identify and address at least one key challenge that their organization faces to improve their direct support workforce turnover and retention rates. This work expanded in years 4 and 5 to include Caregivers for people with disabilities and seniors and was renamed the Tennessee LTSS Workforce Quality Improvement Initiative. This report summarizes the results of year 5 of Tennessee’s annual workforce survey.

For more information about the University of Minnesota’s efforts on the Tennessee LTSS Workforce Quality Improvement Initiative, please contact dsp-tn@umn.edu.

Suggested Citation:

• Pettingell, S., Kleist, B., Sanders, M., Oteman, Q., & Bershadsky, J. (2023). Tennessee LTSS Workforce Quality Improvement Survey 2022 Year Five Report. Minneapolis: University of Minnesota, Institute on Community Integration, Research and Training Center on Community Living.

Report layout and design by Sarah Curtner and Shawn Lawler.

Background

The direct support workforce continues to be among occupations with the highest growth rate in the United States. It has grown significantly in the last decade from 3.2 million to 4.8 million workers in 2021, and it is expected to grow to include another 1 million workers by 2031 (PHI, 2023). The demand for workers continues to exceed the number of new workers wanting to enter this profession. This results in sustained high vacancy rates and staff shortages. Organizations struggle to retain workers after they are hired due to competition for workers with other industries, low wages, and lack of access to affordable benefits. This direct support workforce shortage is an ongoing crisis across the U.S. and is particularly challenging within Home and Community Based Services (HCBS) for persons with intellectual and developmental disabilities (IDD; Scales, 2020). Direct Support professionals (DSPs) and Caregivers provide critical support for people with disabilities including people with intellectual and developmental disabilities and seniors so that they can live, work, and be fully engaged in their community.

Caregiver/Direct Support Professional (DSP): For this survey, defined as an employee whose primary responsibilities include providing personal assistance, support, training, and supervision to people with disabilities and seniors. They may have titles such as caregiver, DSP, direct care worker, family model provider, house managers with primarily direct care duties, residential aide, job coach, home health aide, personal care assistant, and many other titles. At least 50% of a Caregiver/DSP’s hours are spent in direct support tasks (e.g., personal care, home care, community integration). Caregivers/DSPs may perform some supervisory tasks, but the focus of their job is direct support work. Nursing and other professional licensed staff (e.g., LPNs and RNs) are not considered Caregivers/DSPs.

In Tennessee and across the U.S., the State Medicaid Agency goals are to decrease the number of people in institutional settings and increase the use of HCBS programs to address waiting lists for services. These goals cannot be met without strategic efforts to ensure a sufficient and stable number of Caregivers/DSPs available to provide community services. People with disabilities including people with intellectual and developmental disabilities and seniors who experience greater Caregiver/DSP turnover have more injuries and instances of abuse and neglect. The health and safety of people with intellectual and developmental disabilities increases when DSPs have longer tenure (Friedman, 2021a). Community living for people with disabilities and seniors is also compromised when effective and timely solutions to the Caregiver/DSP workforce shortage are not available, funded, and evaluated.

There is a critical need for collection, analysis, and use of organization, program, and state level comprehensive workforce data to identify and match solutions to recruit and retain Caregivers/DSPs in organizations that provide services and supports to people with IDD, physical disabilities, and seniors. Workforce solutions such as ongoing staff development can significantly improve the services of an organization as well as the health and safety of the people they serve (Friedman, 2021b). To positively impact the workforce crisis, organizations need to have knowledge and skills to improve their recruitment, selection, and retention of DSPs (President’s Committee for People with Intellectual Disabilities, PCPID, 2017). This includes assessing and responding to the added burden placed on an already unstable workforce by COVID-19.

TennCare is Tennessee’s state Medicaid program and administers services to over 1.7 million people. As part of a statewide workforce initiative, TennCare sought a method to regularly collect, analyze, and use organization, program, and state level comprehensive workforce data for its Managed Long-Term Supports and Services (MLTSS) that support HCBS programs for people with disabilities. This effort was initiated in 2019 and is connected to the Quality Improvement in Long-Term Services and Supports (QuILTSS) Initiative. In 2021 the implementation of this annual workforce survey was transferred to the three Tennessee Managed Care Organizations. 2022 was the fifth year of the Tennessee LTSS Workforce Quality Improvement Survey (formerly the QuILTSS Initiative Survey), which was completed by disability and aging provider organizations that deliver primarily Employment and Community First CHOICES and CHOICES (Non-ECF CHOICES) in Tennessee and employ Caregivers/DSPs. This report presents a summary of data from 154 provider organizations that completed the 2022 survey regarding their workforce in those service types.

Year Five Methodology

Year Five Survey Development & Administration

The year five survey (using calendar year 2022 data) maintained the same format as the year four survey and was approved by TennCare and the Managed Care Organization (MCO) leads from Amerigroup, BlueCare TN, and UnitedHealthcare. The finalized survey was converted into an online format using Qualtrics. A printable version was also available for organizations to use in the data collection process. An internal pilot test was conducted to ensure the online survey functionality. An external pilot test was not needed because the content and format of this survey was the same as year four. The year five survey launched on June 1, 2023. A webinar was delivered on June 7, 2023, for all organizations invited to complete the year five survey. The purpose of the webinar was to introduce the survey, clarify survey questions that were more difficult for participants in previous years, and to answer questions. The webinar was recorded and made available on demand for organizations who were unable to attend and as a resource for all organizations to reference as they were completing the survey. The survey closed on July 28, 2023. Throughout the data collection and cleaning phases, follow-up was done with all organizations who provided data that were inconsistent and/or had other issues that needed clarification. Data management and report analyses were conducted from July 31, 2023, to August 11, 2023.

Recruitment, Sample, and Response Rate

The Amerigroup, BlueCare TN, and UnitedHealthcare MCOs provided a list of 381 organizations that represent Tennessee's Home and Community Based Services (HCBS) Programs - CHOICES (Non-ECF CHOICES), Employment Community First CHOICES (ECF), and 1915(c) Waiver Programs. Of these, 29 (8%) indicated they did not meet the qualification criteria (e.g., nature of provider operations, services offered, and organization restructuring that may occur immediately before or during the survey), 2 (0.5%) reported closing their operations, and 6 (2%) were duplicative of other organizations in the list, which left a sample of 344 organizations who were sent an invitation letter by email and links to participate in the year five survey.

Of the 344 organizations targeted in year five, 154 (45%) completed a year five survey, 42 (12%) started the survey but did not complete it, 132 (38%) did not respond at all, and 16 (5%) declined to participate. Of the 154 submitted surveys, 25 (16%) participated in year one, 36 (23%) participated in year two, 40 (26%) participated in year three, 84 (55%) participated in year 4, and 59 (38%) were new participants. The analytic sample for year 5 was 154 organizations.

Organizations were grouped into three regions for the regional analysis. Regional analyses were conducted based on the region where the organization provided the highest percentage of their services, which may differ from the location of their administrative/corporate/central office. Of the 154 organizations, 47 (31%) provided their highest percentage of service in the East counties, 54 (35%) provided their highest percentage of service in the Middle counties, and 53 (34%) provided their highest percentage of service in the West counties. There was 1 organization that provided equal amounts of services in multiple regions, meaning there was no highest region. The item asking the location of their administrative/corporate/central office was blank, but a Google search placed them in the East region.

154 organizations completed the year five survey reporting on calendar year 2022. In previous cycles, 131 organizations completed the year four survey reporting on calendar year 2021, 63 organizations completed the year three survey reporting on calendar year 2020, 75 organizations completed the year two survey reporting on calendar year 2019, and 47 organizations completed the year one survey reporting on calendar year 2018.

Year Five Results

This initiative includes organizations providing data on the services and supports they provide in the intellectual and developmental disabilities (IDD) and aging and disabilities sectors. Years one, two and three focused solely on the sector of workforce providing services to individuals with IDD. Years four and five introduced organizations in the aging and disabilities sector. This means caution needs to be taken when examining trends over time recognizing the samples are different across time.

This report provides an overview of state level survey data. State and regional data profiles are available in Appendix A. Survey items were analyzed by region when there was a large enough sample size. Regional breakdowns were based on where the organization’s highest percentage of services were located. Unless otherwise specified, responses to survey questions reflect calendar year 2022. It is important to note that while 154 organizations participated in the survey, not all organizations answered all questions.

Lastly, due to data limitations such as incomplete or inconsistent responses, results for COVID-19 experiences were unable to be reported.

Organization Background

For the purposes of reporting the initiatives workforce survey data, the state was broken down into three geographic regions. The percentage of organizations who provided services in each region are depicted in Figure 1. Counties included by region:

• East: Anderson, Bledsoe, Blount, Bradley, Campbell, Carter, Claiborne, Cocke, Cumberland, Grainger, Greene, Hamblen, Hamilton, Hancock, Hawkins, Jefferson, Johnson, Knox, Loudon, McMinn, Marion, Meigs, Monroe, Morgan, Polk, Rhea, Roane, Scott, Sevier, Sullivan, Unicoi, Union, Washington
• Middle: Bedford, Cannon, Cheatham, Clay, Coffee, Davidson, DeKalb, Dickson, Fentress, Franklin, Giles, Grundy, Hickman, Houston, Humphreys, Jackson, Lawrence, Lewis, Lincoln, Macon, Marshall, Maury, Montgomery, Moore, Overton, Perry, Pickett, Putnam, Robertson, Rutherford, Sequatchie, Smith, Stewart, Sumner, Trousdale, Van Buren, Warren, Wayne, White, Williamson, Wilson
• West: Benton, Carroll, Chester, Crockett, Decatur, Dyer, Fayette, Gibson, Hardeman, Hardin, Haywood, Henderson, Henry, Lake, Lauderdale, Madison, McNairy, Obion, Shelby, Tipton, Weakley

• Tennessee East: 30%
• Tennessee Middle: 35%
• Tennessee West: 35%

Figure 1 indicates the percent of services that 154 organizations provided in the East, Middle, and West regions of Tennessee. In the state, 30% of organizations provided services in the East region, 35% provided services in the Middle region, and 35% provided services in the West region.

When looking at administrative office headquarters, 28% (42 organizations) had their administrative office in the East region, 37% (57 organizations) were located in the Middle region, and 35% (54 organizations) were located in the West region. The majority of organizations provided services in one region (85%), though 7% provided services in two regions and 8% provided services in three regions.

• years in business
  • fewer than 1: 0%
  • 1-5: 8%
  • 6-10: 19%
  • more than 10: 73%
• years delivering services
  • fewer than 1: 1%
  • 1-5: 10%
  • 6-10: 19%
  • more than 10: 71%

As seen in Figure 2, most organizations statewide (73%) have been in business for 10 or more years, 19% for 6 to 10 years, 8% for 1-5 years, and none for less than one year. Similarly, most organizations (71%) have provided services for 10 or more years, 19% for 6 to 10 years, 10% for 1 to 5 years, and 1% for less than 1 year.

• family or individual homes: 65%
• agency or facility sites: 24%
• job sites: 6%
• other: 5%

Figure 3 summarizes the types of sites/setting where services are provided by the organizations across the state. Organizations provided services in several settings, including agency/facility sites, family or individual homes, job sites, and other sites. Statewide, organizations most often provided services in family or individual homes (65%), followed by agency or facility sites (24%), job sites (6%), and other sites (5%). The other category includes all sites that did not fit into the listed service site categories.

In the East, 32% of organizations reported providing services in agency or facility sites, 52% provided services in family or individual homes, 10% provided services in job sites, and 6% provided services in other settings. In the Middle, 23% of organizations provided services in agency or facility sites, 70% provided services in family or individual homes, 2% provided services in job sites, and 5% provided services in other settings. In the West, 16% of organizations provided services in agency or facility sites, 73% provided services in family or individual homes, 7% provided services in job sites, and 4% provided services in other settings.

People Served

DIDD = Department of Intellectual and Developmental Disability

ECF CHOICES = Employment and Community First CHOICES

CHOICES (Non-ECF CHOICES) = Non-Employment and Community First CHOICES

VR = Vocational Rehabilitation

Organizations provided services across DIDD, ECF CHOICES, CHOICES (Non-ECF CHOICES), and VR services. Across the state, the average number of people for whom organizations provided DIDD, ECF CHOICES, CHOICES (Non-ECF CHOICES), and/or VR services was 72 people (range 1 to 966 people). The average number of people served in the East region was 90 (range 1 to 816 people) in 46 organizations. The average number of people served in the Middle region was 80 (range 1 to 966 people) in 53 organizations. The average number of people served in the West region was 47 (range 1 to 296 people) in 51 organizations.

Organization Staffing

The organizations who responded to the survey supported a total of 10,761 people who are aging, have physical disabilities or those with I/DD and employed a total of 14,458 staff. As seen in Figure 4, this included:

• 11,311 Caregivers/DSPs
• 640 Frontline Supervisors (FLSs)
• 475 managers
• 985 administrators, and
• 1,048 other staff.

In the East region, there were 4,117 people served by 46 organizations with supports from 4,287 Caregivers/DSPs and 326 FLSs. There were 249 managers, 476 administrators, and 498 other staff. There were 5,835 total staff in the East. In the Middle region, there were 4,256 people served by 53 organizations with supports from 4,220 Caregivers/DSPs and 210 FLSs. There were 123 managers, 398 administrators, and 418 other staff. There were 5,369 total staff in the Middle. In the West region, there were 2,388 people served by 51 organizations with supports from 2,804 Caregivers/DSPs and 104 FLSs. There were 103 managers, 111 administrators, and 132 other staff. There were 3,254 total staff in the West.

• people served: 10, 761
• Caregivers/DSPs: 11,311
• FLSs: 640
• managers: 475
• administrative: 985
• other staff: 1,048
• total staff: 14,458

On average across the state, organizations employed 75 Caregivers/DSPs, including on-call, temporary, and relief positions; 4 FLSs; 3 managers; 7 administrators (e.g., administrative, executive director, human resources/payroll); and 7 other employees.

Organizations were asked to report the number of full-time, part-time, and on-call Caregivers/DSPs they employ. Fifty-four percent of Caregivers/DSPs (54%) were full-time, 43% were part-time, and 3% were on-call/temporary or relief staff. Fifty-five percent of Caregivers/DSPs worked across more than one service type. Figure 5 shows this Caregiver/DSP staffing pattern in the state.

• 54% were full-time
• 43% were part-time
• 3% were on-call/temporary or relief staff

There were some regional differences in Caregiver/DSP staffing patterns.

• In the East, 64% were full-time, 32% were part-time, and 4% were on-call/temporary or relief staff. Fifty-seven percent of the Caregivers/DSPs worked across more than one service type.
• In the Middle, 59% were full-time, 37% were part-time, and 4% were on-call/temporary or relief staff. Fifty-one percent of the Caregivers/DSPs worked across more than one service type.
• In the West, 38% were full-time, 60% were part-time, and 2% were on-call/temporary or relief staff. Fifty-seven percent of the Caregivers/DSPs worked across more than one service type.

Most organizations defined their part-time and full-time positions by the number of hours worked per week. Of the 149 organizations who specified the number of hours per week a Caregiver/DSP needs to work to be considered full-time, 1% required Caregivers/DSPs to work 29 hours per week or less, 43% at least 30-34 hours, 17% at least 35-39 hours, and 30% at least 40 hours per week. Fourteen organizations indicated that full-time staff are designated based on federal and state guidelines for full-time employment; others reported they do not have full-time employees or have all contract/PRN employees.

For the 46 organizations in the East region who specified the number of hours per week a Caregiver/DSP needs to work to be considered full-time, none required Caregivers/DSPs to work 29 hours per week or less, 56% at least 30-34 hours, 20% at least 35-39 hours, 20% at least 40 hours per week, and 4% selected the other category. For the 53 organizations in the Middle region who specified the number of hours per week a Caregiver/DSP needs to work to be considered full-time, 2% required Caregivers/DSPs to work 29 hours per week or less, 42% at least 30-34 hours, 19% at least 35-39 hours, 24% at least 40 hours per week, and 13 selected the other category. For the 50 organizations in the West region who specified the number of hours per week a Caregiver/DSP needs to work to be considered full-time, 2% required 29 hours per week or less, 30% at least 30-34 hours, 12% at least 35-39 hours, 46% at least 40 hours per week, and 10% selected the other category.

Caregivers/Direct Support Professionals

Caregiver/Direct Support Professional Wages

Enhanced HCBS FMAP Funds are dollars being used within Tennessee’s Home and Community Based Services (HCBS) Programs—CHOICES (Non-ECF CHOICES), Employment Community First CHOICES (ECF), and 1915(c) Waiver Programs—to increase access to HCBS, strengthen the HCBS workforce, and build organization capacity to meet the needs of individuals receiving HCBS in these programs (Moss, 2022). Tennessee as a whole, through their legislature, allocated and approved three consecutive year increases, resulting in the most recent $15 average wage. Tennessee does not mandate a specific rate for the frontline workforce, but the first of two rate increases required the vast majority of the new appropriations to go to the frontline workforce.

Organizations reported on the wages paid to Caregivers/DSPs, including starting wages, average wages, and highest wages paid on December 31, 2022. Organizations reported regular wages paid and did not include overtime wages. All data about wages were reported for part-time Caregivers/DSPs, full-time Caregivers/DSPs, and all Caregivers/DSPs. Among all Caregivers/DSPs statewide, the average wages are indicated in Figure 6. The average starting wage for all Caregivers/DSPs was $13.21, the overall average wage for all Caregivers/DSPs was $13.69, and the average highest wage for all Caregivers/DSPs was $14.95.

Organizations were asked to report whether Caregivers/DSPs who work in different service types are paid the same wage for each service. Overall, 11% of organizations pay Caregivers/DSPs different wages for different service types. In the East region 2% of organizations pay Caregivers/DSPs different wages for different service types. In the Middle region the percentage is higher, with 24% of organizations paying Caregivers/DSPs different wages for different service types. In the West region 6% pay Caregivers/DSPs different wages for different service types.

• starting: $13.21
• highest: $14.95
• average: $13.69

Caregiver/Direct Support Professional Starting Wages

The average starting wage for part-time Caregivers/DSPs was $13.22 (range $7.00 to $16.00). The average starting wage for full-time Caregivers/DSPs was $13.52 (range $10.00 to $16.00). The average starting wage for Caregivers/DSPs overall was $13.21 (range $7.00 to $16.00). These wages are depicted in Figure 7.

• overall
  • state (140): $13.21
  • east (44): $13.26
  • middle (50): $13.48
  • west (46): $12.88
• full-time
  • state (77): $13.52
  • east (24): $13.39
  • middle (34): $13.75
  • west (21): $13.30
• part-time
  • state (76): $13.22
  • east (24): $13.09
  • middle (34): $13.61
  • west (18): $12.64

The number of responding organizations is in parenthesis.

The average starting wage was similar across regions.

• In the East, the average starting wage for part-time Caregivers/DSPs was $13.09 (range $10.00 to $16.00). The average starting wage for full-time Caregivers/DSPs was $13.39 (range $10.00 to $16.00). The average starting wage for all Caregivers/DSPs was $13.26 (range $10.00 to $16.00).
• In the Middle, the average starting wage for part-time Caregivers/DSPs was $13.61 (range $10.50 to $15.00). The average starting wage for full-time Caregivers/DSPs was $13.75 (range $10.50 to $15.00). The average starting wage for all Caregivers/DSPs was $13.48 (range $10.50 to $15.00).
• In the West, the average starting wage for part-time Caregivers/DSPs was $12.64 (range $7.00 to $16.00). The average starting wage for full-time Caregivers/DSPs was $13.30 (range $10.00 to $16.00). The average starting wage for all Caregivers/DSPs was $12.88 (range $7.00 to $16.00).

Average Caregiver/Direct Support Professional Wages

• overall
  • state (136): $13.69
  • east (41): $14.00
  • middle (51): $13.81
  • west (44): $13.25
• full-time
  • state (74): $13.94
  • east (22): $13.97
  • middle (31): $14.09
  • west (21): $13.68
• part-time
  • state (75): $13.64
  • east (25): $13.48
  • middle (33): $13.97
  • west (17): $13.25

The number of responding organizations is in parenthesis.

Organizations reported their average wages for part-time, full-time, and all Caregivers/DSPs. The average part-time Caregiver/DSP wage was $13.64 (range $10.00 to $18.50). The average full-time Caregiver/DSP wage was $13.94 (range $11.00 to $17.01). The average overall Caregiver/DSP wage was $13.69 (range $10.00 to $17.01). Figure 8 indicates the part-time, full-time, and overall wages. As with the starting wages, there is some variation in Caregiver/DSP average hourly wages by region.

• In the East, the average wage for part-time Caregivers/DSPs was $13.48 (range $10.50 to $18.50). The average wage for full-time Caregivers/DSPs was $13.97 (range $11.20 to $17.01). The average wage for all Caregivers/DSPs was $14.00 (range $11.00 to $17.01).
• In the Middle, the average wage for part-time Caregivers/DSPs was $13.97 (range $11.00 to $16.14). The average wage for full-time Caregivers/DSPs was $14.09 (range $11.00 to $16.14). The average wage for all Caregivers/DSPs was $13.81 (range $10.01 to $16.14).
• In the West, the average wage for part-time Caregivers/DSPs was $13.25 (range $10.00 to $16.00). The average wage for full-time Caregivers/DSPs was $13.68 (range $11.00 to $16.00). The average wage for all Caregivers/DSPs was $13.25 (range $10.00 to $16.00).

Highest Caregiver/Direct Support Professional Wages

• overall
  • state (135): $14.95
  • east (41): $15.44
  • middle (49): $15.28
  • west (45): $14.14
• full-time
  • state (76): $15.30
  • east (23): $15.84
  • middle (31): $15.71
  • west (22): $14.14
• part-time
  • state (74): $14.49
  • east (22): $14.87
  • middle (32): $14.55
  • west (20): $14.00

The number of responding organizations is in parenthesis.

Organizations were asked to report the highest wages paid to Caregivers/DSPs in their organization by full-time, part-time, and all Caregivers/DSPs. The average highest wage for part-time Caregivers/DSPs was $14.49 (range $10.00 to $19.00). The average highest wage for full-time Caregivers/DSPs was $15.30 (range $11.00 to $23.23). The average highest wage for all Caregivers/DSPs was $14.95 (range 10.00 to $27.00). Figure 9 indicates the part-time, full-time, and overall wages. Compared to the starting and average hourly wages, there is more variation in Caregiver/DSP average highest hourly wages by region.

• In the East, the average highest wage for part-time Caregivers/DSPs was $14.87 (range $10.90 to $19.00). The average highest wage for full-time Caregivers/DSPs was $15.84 (range $11.15 to $23.23). The average highest wage for all Caregivers/DSPs was $15.44 (range $11.00 to $23.23).
• In the Middle, the average highest wage for part-time Caregivers/DSPs was $14.55 (range $12.50 to $17.00). The average highest wage for full-time Caregivers/DSPs was $15.71 (range $12.50 to $19.19). The average highest wage for all Caregivers/DSPs was $15.28 (range $12.50 to $20.00).
• In the West, the average highest wage for part-time Caregivers/DSPs was $14.00 (range $10.00 to $16.00). The average highest wage for full-time Caregivers/DSPs was $14.14 (range $11.00 to $17.06). The average highest wage for all Caregivers/DSPs was $14.14 (range $10.00 to $27.00).

Caregiver/Direct Support Professional Wage Increases & Bonuses

Organizations were asked to report on whether they provided wage increases to Caregivers/DSPs in three different ways and the average amount they paid for each wage increase. Additionally, organizations reported on whether they provided different types of bonuses to Caregivers/DSPs and the average amount they paid for calendar year 2022.

Hourly Wage Increases

Wage Increases after Training was Completed

Organizations were asked whether they routinely gave an hourly wage increase for Caregivers/DSPs after training was completed. As a reminder, there were 47 organizations in the East region, 54 in the West, and 53 in the West. Due to data limitations, monetary amounts are not reported this year.

As seen in Table 1, 56% of organizations across the state provided an hourly wage increase for Caregivers/DSPs once training was completed. In the East, 55% of organizations gave an hourly wage increase for Caregivers/DSPs once training was completed. In the Middle, 61% of organizations reported an hourly wage increase for Caregivers/DSPs once training was completed. In the West, 51% of organizations reported an hourly wage increase for Caregivers/DSPs once training was completed.

Wage Increases for Longevity

Organizations were asked whether Caregivers/DSPs earned hourly wage increases for longevity of employment (e.g., end of first year, after three years) in 2022. Statewide, 46% of organizations provided an hourly wage increase to Caregivers/DSPs for longevity. In the East, 50% of organizations gave hourly wage increases for longevity to Caregivers/DSPs. In the Middle, 38% of organizations gave an hourly wage increase to Caregivers/DSPs for longevity. In the West, 50% of organizations gave hourly wage increases for longevity to Caregivers/DSPs (see Table 1).

Organizations indicated at which points they offer wage increases based on number of months post hire. They could check all that applied to their organization’s practices for when they offer these wage increases to Caregivers/DSPs. Table 2 shows the points when these increases are given after a Caregiver/DSP is hired. Of the organizations who gave hourly wage increases for longevity, 22% gave an hourly wage increase for longevity between 1-3 months after hire, 15% between 4-6 months, 11% between 7-9 months, and 57% between 10-12 months after hire. There were insufficient responses to report at the regional level.

Other Wage Increases

The survey also asked organizations if they offered hourly wage increases to Caregivers/DSPs for reasons other than longevity in 2022. As seen in Table 1, 59% of the organizations provided wage increases for reasons other than longevity across the state. The percentage of organizations who gave hourly wage increases for reasons other than longevity varied across the regions of Tennessee. In the East, 68% of organizations gave hourly wage increases for reasons other than longevity to Caregivers/DSPs. In the Middle, 67% of organizations gave hourly wage increases for reasons other than longevity to Caregivers/DSPs. In the West, 41% of organizations gave hourly wage increases to Caregivers/DSPs for reasons other than longevity.

Caregiver/Direct Support Professional Bonuses

Questions about monetary referral, hiring, years of service, and performance recognition bonuses were added to the year three survey. Due to data limitations, monetary amounts and number of employees receiving them are not reported this year.

Referral bonus

Organizations may give referral bonuses to current employees to encourage inside recruitment. The employees share information about the work with people they know whose skills and interests are a good fit for the position. The referral bonus is generally given to the employee after the new hire remains in the position for a specified amount of time to ensure qualified, interested individuals are recruited. As seen in Table 3, 50% of organizations gave a referral bonus to Caregivers/DSPs across the state. By region, 54% of organizations provided referral bonuses in the East, 57% provided referral bonuses in the Middle, and 39% of organizations provided referral bonuses in the West.

Hiring bonus

A hiring bonus is generally provided to the newly hired employee as an incentive to attract individuals to the organization. Typically, part of the hiring bonus is paid shortly after hire, and part is paid at a specified time after hire. Throughout the state, 25% of organizations provided a hiring bonus to newly hired Caregivers/DSPs. By region, 27% of organizations provided hiring bonuses in the East, 32% of organizations provided hiring bonuses in the Middle, and 18% of organizations provided hiring bonuses in the West (see Table 3).

Years of service bonus

A bonus for years of service is awarded for pre-specified points in employee tenure (e.g., end of 1 year, 5 years, 10 years, etc.). As seen in Table 3, 33% of organizations gave a bonus to Caregivers/DSPs for years of service across the state. By region, 18% of organizations provided years of service bonuses in the East, 50% of organizations provided years of service bonuses in the Middle, and 28% of organizations provided years of service bonuses in the West.

Performance recognition bonus

Performance recognition is when employees are rewarded for their behavior, effort, or achievement that is above expectation and supports the organization’s mission, vision, and values. Throughout the state, 32% of organizations gave a performance recognition bonus to Caregivers/DSPs. By region, 30% of organizations provided performance recognition bonuses in the East, 41% of organizations provided performance recognition bonuses in the Middle, and 24% of organizations provided recognition bonuses in the West (see Table 3).

Other bonuses

Across the state, 25% of organizations provided bonuses to Caregivers/DSPs for reasons other than employee referral, hiring, years of service, or performance recognition bonuses. By region, 31% of organizations provided a bonus for other reasons in the East, 26% of organizations provided a bonus for other reasons in the Middle, and 20% of organizations provided a bonus for other reasons in the West (see Table 3). Organizations were asked to specify the other reasons they provided bonuses. The other reasons they provided were:

• Vacation Bonus
• Safety Bonus
• Annual/Semi-annual Bonus
• Attendance
• Employee of the Month
• Holiday Bonus
• End of Year Bonus
• FMAP Funds
• Loyalty to Company
• Christmas/winter bonus
• Retention bonus.

Caregiver/Direct Support Professional Work Hours and Overtime

Organizations were asked to respond to questions about the number of hours Caregivers/DSPs worked per week and the number of hours of overtime Caregivers/DSPs are working on average. Overtime is a significant cost in the long-term services and support system. Many Caregivers/DSPs rely on overtime to earn a livable wage. In a study of DSPs in Minnesota, 68% of DSPs reported that they would work more hours or overtime if they were available at their primary employer (Hewitt et al., 2019). Nearly 30% of DSPs in that survey worked a second job. Depending on settings where services are provided (e.g., residential), high Caregivers/DSP vacancy rates may necessitate that Caregivers/DSPs work overtime hours. Reporting the number of hours Caregivers/DSPs work per week allows organizations to look at labor costs, staffing patterns, and the number of part-time and full-time staff an organization employs. Overtime data provides organizations with important information that can be used to calculate the cost of turnover.

Caregiver/Direct Support Professional Work Hours

Organizations reported the average number of hours, including overtime, that Caregivers/DSPs worked per week. The average number of hours Caregivers/DSPs worked per week is summarized in Table 4.

Across all organizations throughout the state, Caregivers/DSPs worked an average of 34 (range 1 to 80) hours per week. For organizations who could differentiate between part-time and full-time employees, part-time Caregivers/DSPs worked an average of 23 (range 5 to 50) hours per week and full-time Caregivers/DSPs worked an average of 40 (range 5 to 90) hours per week.

• In the East region across all organizations, Caregivers/DSPs worked an average of 37 (range 5 to 80) hours per week. For organizations who could differentiate between part-time and full-time employees, part-time Caregivers/DSPs worked an average of 26 (range 15 to 50) hours per week and full-time Caregivers/DSPs worked an average of 41 (range 5 to 90) hours per week.
• In the Middle region across all organizations, Caregivers/DSPs worked an average of 35 (range 1 to 77) hours per week. For organizations who could differentiate between part-time and full-time employees, part-time Caregivers/DSPs worked an average of 22 (range 5 to 33) hours per week and full-time Caregivers/DSPs worked an average of 42 (range 24 to 77) hours per week.
• In the West region across all organizations, Caregivers/DSPs worked an average of 29 (range 5 to 50) hours per week. For organizations who could differentiate between part-time and full-time employees, part-time Caregivers/DSPs worked an average of 21 (range 10 to 40) hours per week and full-time Caregivers/DSPs worked an average of 35 (range 5 to 57) hours per week.

Caregiver/Direct Support Professional Overtime Hours

Organizations reported overtime hours paid to Caregivers/DSPs in 2022. Figure 10 indicates the overall number of overtime hours paid to Caregivers/DSPs in 2022. Across the state, the average number of overtime hours that organizations paid out to Caregivers/DSPs in 2022 was 18,600 (range 0 to 332,852). The total number of overtime hours paid out in 2022 by 129 organizations was 2,399,338. In the East, the average number of overtime hours paid out was 18,783 (range 0 to 108,694) with a total of 751,338 overtime hours paid to Caregivers/DSPs. In the Middle, the average number of overtime hours paid out was 28,403 (range 0 to 332,852) with a total of 1,278,130 overtime hours paid to Caregivers/DSPs. In the West, the average number of overtime hours paid out was 8,406 (range 0 to 168,745) with a total of 369,869 overtime hours paid to Caregivers/DSPs.

Caregiver/Direct Support Professional Cost of Overtime

A key workforce issue nationwide for organizations that employ Caregivers/DSPs is the high level of Caregiver/DSP overtime hours. As vacancy rates and turnover increases, Caregivers/DSPs are asked to work more hours to fill in those missing employee hours. Overtime can be the bridge for Caregivers/DSPs to make a living wage, but at the same time, overtime is costly to organizations, and that expense may be better utilized to increase wages for all DSPs (Spreat, 2021). This, paired with the demand for Caregivers/DSPs exceeding the supply of workers, often leads to high burnout rates resulting in inconsistent continuity and quality of care and higher vacancy rates. Annual turnover, departure in the first year of employment (early separation within 0-6 months of hire and turnover within 6-12 months of hire), and vacancy rates among full-time, part-time, and all Caregivers/DSPs employed were computed for this report.

Measuring Cost of Overtime

The formula used to compute annual total cost of overtime was calculated using two variables: the total number of Caregiver/DSP overtime hours paid out in calendar year 2022, and the average hourly Caregiver/DSP wage. The average Caregiver/DSP hourly wage was divided by 2 and multiplied by the number of overtime hours in 2022. This gives the wage for the extra time – the extra one-half (assuming time and a half pay for extra hours). And, when multiplied by the number of overtime hours, it produces the cost of the extra time.

Across the state, the average cost of Caregiver/DSP overtime in 2022 was $140,165 (range $0 to $2,466,433) for participating organizations. The total cost of Caregiver/DSP overtime in 2022 from 122 organizations was $17,100,135.

• In the East region, the average cost of Caregiver/DSP overtime in 2022 was $150,139 (range $0 to $751,619). The total cost of Caregiver/DSP overtime in 2022 from 37 organizations was $5,555,127.
• In the Middle region, the average cost of Caregiver/DSP overtime in 2022 was $205,287 (range $0 to $2,466,433). The total cost of Caregiver/DSP overtime in 2022 from 44 organizations was $9,032,631.
• In the West region, the average cost of Caregiver/DSP overtime in 2022 was $61,277 (range $0 to $1,265,584). The total cost of Caregiver/DSP overtime in 2022 from 41 organizations was $2,512,377.

The cost of overtime for the state in 2022 is shown in Figure 11.

Caregiver/Direct Support Professional Retention

Caregiver/DSP retention is addressed in this survey by considering vacancy rates, turnover (crude separation), and reasons for departure. The best strategy to ensure a sufficient workforce, as well as address the high demand and staff shortages, is to keep staff once they are hired.

Caregiver/Direct Support Professional Vacancy Rate

High Caregiver/DSP vacancy rates may be due to factors such as changing demographics in the U.S., the aging of the population, low unemployment rates that increases demand for workers to fill open positions, and growth in long-term services and supports (Campbell et al., 2021). The response to the COVID-19 pandemic has also shifted the landscape in ways that supports are provided and the willingness of workers to fill human service positions (Hewitt, Pettingell, Bershadsky, et al., 2021). Organizations also report that they have difficulties recruiting people to fill open positions due to terminations (voluntary and involuntary) and growth in the need for services. For these reasons, the vacancy rate is an important data point to capture for this workforce.

Measuring Vacancy Rate

The Caregiver/DSP vacancy rate was calculated for this report using two variables: total number of funded positions currently vacant and the total number of funded positions at the site. Vacancy rate was measured using the following formula:

Vacancy rates across the state are shown in Figure 12. The average vacancy rate among all Caregiver/DSP positions was 17%. The average vacancy rate for part-time positions was 26%, and the average vacancy rate for full-time positions was 16%.

• 17% overall vacancy rate
• 26% of part-time positions were vacant
• 16% of full-time positions were vacant

In the East, the average vacancy rate among full-time Caregivers/DSPs was 13%. The average part-time Caregiver/DSP vacancy rate was 27%. The average vacancy rate among all Caregiver/DSP positions was 17%. In the Middle, the average vacancy rate among full-time Caregivers/DSPs was 16%. The average part-time Caregiver/DSP vacancy rate was 26%. The average vacancy rate among all Caregiver/DSP positions was 16%. In the West, the average vacancy rate among full-time Caregiver/DSP positions was 19%. The average vacancy rate among part-time Caregiver/DSP positions in the West region was 25%. The average vacancy rate among all Caregiver/DSP positions was 18%.

Caregiver/Direct Support Professional Turnover

A key workforce issue nationwide for organizations that employ Caregivers/DSPs is the high level of Caregiver/DSP turnover. This, paired with the demand for Caregivers/DSPs exceeding the supply of workers, often leads to high vacancy rates. Annual turnover, departure in the first year of employment (early separation within 0-6 months of hire and turnover within 6-12 months of hire), and vacancy rates among full-time, part-time, and all Caregivers/DSPs employed were computed for this report.

Measuring Turnover

The formula used to compute turnover (annual crude separation rate) was calculated using three variables: the number of Caregivers/DSPs who left in the past year, the total number of Caregivers/DSPs employed, and the number of Caregiver/DSP vacancies. The crude separation rate was defined as:

Across the state, annual turnover for full-time Caregivers/DSPs in calendar year 2022 was 46%. Turnover among part-time Caregivers/DSPs was 57%. The overall Caregiver/DSP annual turnover rate was 61%.

• In the East, the average turnover rate among full-time Caregivers/DSPs was 57%. Among part-time Caregivers/DSPs, the average turnover rate was 45%. The average turnover rate among all Caregivers/DSPs in the region was 54%.
• In the Middle, the average turnover rate among full-time Caregivers/DSPs was 38%. Among part-time Caregivers/DSPs, the average turnover rate was 55%. The average turnover rate for all Caregivers/DSPs in the Middle region was 51%.
• In the West, the average turnover rate among full-time Caregivers/DSPs was 43%. The average turnover rate among part-time Caregivers/DSPs was 70%. The average turnover rate among all Caregivers/DSPs in the West region was 79%.

The rates for turnover within the first year of employment are shown in Figure 13.

Overall turnover was 61%.

Of those who left:

• 61% left within 0-6 months of hire
• 28% left within 6-12 months of hire

Caregiver/Direct Support Professional Separations Within 0-6 and 6-12 Months

Early separation within the first six months of employment is a critical factor to consider when addressing retention challenges. It is often an indicator that an employee’s expectations were unmet or the position was not a good fit. It is an indication that the organization is not carefully selecting new hires but instead hiring people who meet the bare minimum qualifications. Turnover is extremely costly for organizations, estimated between $3,278-4,872 per DSP who leaves (Larson et al., 2016). It’s important to note that these data were collected in the early 2000s and have not been adjusted for inflation. Early separation is also detrimental for people who receive DSP supports as there is little time to develop a professional relationship with a DSP before a new one is hired (Friedman, 2018). Additionally, every Caregiver/DSP who leaves the organization requires an existing employee to work extra hours and backfill the vacated shifts while a new Caregiver/DSP is hired and trained. Data were gathered to show the percentage of Caregivers/DSPs who left within their first year of employment.

Within 0-6 Months of Hire

The Caregiver/DSP separation rate within 0 to 6 months of hire was calculated using two variables: the number of Caregivers/DSPs who left in the past year and the total number of Caregivers/DSPs who left within 0 to 6 months of being hired. The 0 to 6 month separation rate was defined as:

In the state, the average Caregiver/DSP separation rate within 0 to 6 months of hire was 61% across all Caregivers/DSPs, 67% for part-time Caregivers/DSPs, and 50% for full-time Caregivers/DSPs. In the East region, the average Caregiver/DSP separation rate within 0 to 6 months of hire was 57% across all Caregivers/DSPs, 71% for part-time Caregivers/DSPs, and 45% for full-time Caregivers/DSPs. In the Middle region, the average Caregiver/DSP separation rate within 0-6 months of hire was 60% across all Caregivers/DSPs, 61% for part-time Caregivers/DSPs, and 53% for full-time Caregivers/DSPs. In the West region, the average Caregiver/DSP separation rate within 0-6 months of hire was 66% across all Caregivers/DSPs, 72% for part-time Caregivers/DSPs, and 51% for full-time Caregivers/DSPs.

Within 6-12 Months of Hire

The Caregiver/DSP separation rate within 6 to 12 months of hire was calculated using two variables: the number of Caregivers/DSPs who left in the last year and the total number of Caregivers/DSPs who left within 6 to 12 months of being hired. The 6 to 12 month separation rate was defined as:

In the state, the average Caregiver/DSP separation rate within 6 to 12 months of hire was 28% across all Caregivers/DSPs, 26% for part-time Caregivers/DSPs, and 40% for full-time Caregivers/DSPs. In the East region, the average Caregiver/DSP separation rate within 6 to 12 months of hire was 29% across all Caregivers/DSPs, 31% for part-time Caregivers/DSPs, and 43% for full-time Caregivers/DSPs. In the Middle region, the average Caregiver/DSP separation rate within 6 to 12 months of hire was 25% across all Caregivers/DSPs, 23% for part-time Caregivers/DSPs, and 34% for full-time Caregivers/DSPs. In the West region, the average Caregiver/DSP separation rate within 6 to 12 months of hire was 29% across all Caregivers/DSPs, 25% for part-time Caregivers/DSPs, and 45% for full-time Caregivers/DSPs.

Reasons Caregivers/Direct Support Professionals Give for Leaving Their Positions

Most of the organizations who participated (79%) track reasons that Caregivers/DSPs give for leaving their position. Organizations were asked to select the top three reasons that Caregivers/DSPs give for leaving their position. Table 5 shows the percentage of organizations in the state and regions that selected each reason as one of their top three. The table is ordered from greatest to least percentage of organizations in the state.

Organizations in the state selected “No call/No show” (66%) as the most commonly given reason for Caregivers/DSPs leaving their position. “Found another job at another company” (54%) was the second most commonly given reason, and “Pay too low/Needed better pay” (38%) was the third most commonly given reason. “Termination or being fired” (30%), “Not a good fit for the type of work” (21%), “Advanced to a new position within the company in a different service” (8%), and “Could not get along with co-workers” (1%) were selected by some organizations. “Training/support was inadequate”, “Having too little or poor quality time with their supervisor”, and “Not recognized for the work they did” were not selected by any organizations. There were some regional differences in percentages of organizations that selected the reasons, but the largest percentage of organizations selected the same top four reasons in each of the three regions and the state.

Over one-third (32%) of organizations selected “other” as a top reason that Caregivers/DSPs gave for leaving their position. Organizations had the opportunity to write in the “other” reason, which included the following:

• Did not want to do online training
• Clients passed away; burnout from them passing away
• Caregivers just do not want to work
• Failed background check
• Hired but never took a shift
• Job circumstances (e.g., extra hours, extra shifts, etc.)
• Medical reasons
• Personal reasons
• Retirement.

Caregiver/Direct Support Professional Benefits

Benefits are a key component of employee compensation packages. Though wages are often considered the primary issue of concern for any employee, benefits are also important to employees. Looking at benefits that are offered to Caregivers/DSPs and the extent to which they are utilized by Caregivers/DSPs can demonstrate the value of a benefit for Caregivers/DSPs in an organization.

Organizations reported if they offered paid time off (not differentiating between sick leave and paid vacation), sick leave, paid vacation, and health benefits to some or all of their Caregivers/DSPs. Additionally, monetary amounts paid out for paid leave options were reported; however, fewer organizations answered the questions about monetary amounts, so those data should be interpreted with caution.

As seen in Table 6, 40% of the organizations offered paid time off (PTO) to some or all of their Caregivers/DSPs. Of the 45 organizations that reported the money spent on PTO, the average amount was $78,123. Eleven percent of organizations offered paid sick leave to some or all of their Caregivers/DSPs. Of the nine organizations that reported the money spent on paid sick leave, the average amount was $19,076. Eighteen percent of organizations offered paid vacation to some or all of their Caregivers/DSPs. Of the 15 organizations that reported the money spent on paid vacation, the average amount was $25,356.

Health Insurance

Across the state, 55% of the 152 organizations offered health insurance to some or all of their Caregivers/DSPs. On average, the minimum number of hours a Caregiver/DSP had to work per week to be eligible for health insurance was 31 (range 10 to 40 hours). On average, 27% (range 0% to 100%) of Caregivers/DSPs were enrolled in health insurance through their organization.

Organizations reported the average cost per month of health insurance for single, single plus 1, and family coverage for both the organization and the Caregiver/DSP. As seen in Table 7, organizations throughout the state paid an average of $353 (range $0-$1,218) per Caregiver/DSP for health insurance premium contributions each month for single coverage, $386 (range $0-$1,322) for single plus 1 coverage, and $537 (range $0-$2,838) for family coverage. The average employee’s contribution for monthly health insurance premium contribution was $142 (range $0-$668) for single coverage, $391 (range $0-$1,045) for single plus 1 coverage, and $378 (range $0-$1,867) for family coverage.

Frontline Supervisors

A Frontline Supervisor (FLS) is an employee whose primary responsibility is the supervision of Caregivers/DSPs. While these individuals may perform direct support tasks, their primary job duty is to supervise employees and manage programs. They are not viewed by the organization as Caregivers/DSPs, rather the organization views their role as guiding and directing the work of Caregivers/DSPs more than 50% of their time. Caregivers/DSPs report that support, training, mentorship and supervision provided by their FLS are a key reason that they stay in their position; therefore, examining compensation, stability, and vacancy of these positions are important in stabilizing the DSP workforce (Hewitt et al., 2019).

Frontline Supervisor Salaries

Organizations reported FLS starting, average, and highest salaries. For organizations that provided hourly wages instead of salaries, the hourly wage was converted into a salary.

• average salary: $39,469
• starting: $37,177
• highest: $44,797

Figure 14 shows the average FLS starting, average, and highest salaries. The average starting salary for FLSs across the state was $37,177 (range $15,000 to $75,000). By region, the average starting salary for FLSs was $36,379 (range $23,000 to $58,000) in the East, $39,289 (range $28,000 to $75,000) in the Middle, and $35,262 (range $15,000 to $55,000) in the West.

The overall average salary for FLSs across the state was $39,469 (range $15,000 to $83,200). By region, the average salary for FLSs was $38,858 (range $24,000 to $65,000) in the East, $41,956 (range $28,500 to $83,200) in the Middle, and $36,885 (range $15,000 to $55,000) in the West.

The average highest salary for FLSs across the state was $44,797 (range $15,000 to $100,000). By region, the average highest salary for FLSs was $44,283 (range $24,000 to $89,000) in the East, $47,087 (range $30,000 to $100,000) in the Middle, and $42,560 (range $15,000 to $87,000) in the West.

Frontline Supervisor Retention

FLS turnover is a key issue nationwide for stabilizing the direct support workforce. Turnover, early separations, and vacancy for all FLSs were computed for this report. FLS turnover and early separation data are shown in Figure 15.

Frontline Supervisor Turnover

FLS annual turnover was calculated using the annual crude separation rate which uses three variables: the number of FLSs who left in the last year, the total number of FLSs employed, and the number of FLS vacancies. The crude separation rate was defined as:

Overall turnover: 30%

Of those who left:

• 35% left within 0-6 months of hire
• 46% left within 6-12 months of hire

The average FLS turnover throughout the state was 30%. By region, the average turnover of FLSs was 26% in the East, 35% in the Middle, and 29% in the West.

Frontline Supervisor Separations Within 0-6 and 6-12 Months

As with any employee, Frontline Supervisors can find themselves in a situation where they take a job and quickly realize it is not what they expected or they need to leave the job for some reason. In community support for people with disabilities, often FLSs realize that they end up working as many hours as a Caregiver/DSP but make less money because they are often salaried employees and not paid overtime (compared to Caregivers/DSPs who are paid overtime and work many hours of overtime each week). Additionally, FLSs are often promoted from Caregiver/DSP positions and may realize they do not have the necessary skills to be an effective FLS and prefer working as a Caregiver/DSP. Early turnover of FLS can be particularly distressing for Caregivers/DSPs. Data were gathered to show the percentage of supervisors who left within their first year of employment. FLS vacancies are costly to fill, and supervisors provide continuity for the Caregivers/DSPs as higher supervisor turnover may be a predictor for higher Caregiver/DSP turnover.

Within 0-6 Months of Hire

FLS separation rate within 0 to 6 months of hire was calculated using two variables: the number of FLSs who left in the last year and the total number of FLSs who left within 0 to 6 months of being hired. The 0 to 6-month separation rate was defined as:

In the state, the average FLS separation rate within 0 to 6 months of hire was 35%. By region, the average FLS separation rate within 0 to 6 months of hire was 14% in the East, 47% in the Middle, and 35% in the West.

Within 6-12 Months of Hire

FLS separation rate within 6 to 12 months of hire was calculated using two variables: the number of FLSs who left in the last year and the total number of FLSs who left within 6 to 12 months of being hired. The 6 to 12-month separation rate was defined as:

Throughout the state, the average FLS separation rate within 6 to 12 months of hire was 46%. By region, the average FLS separation rate within 6 to 12 months of hire was 50% in the East, 39% in the Middle, and 58% in the West.

Frontline Supervisor Vacancy Rate

FLS vacancy rate was calculated using 2 variables: number of FLS vacancies and total number of FLSs employed. Vacancy rate was measured using the following formula: Total number of funded positions currently vacant divided by the total number of funded positions.

As seen in Figure 16, the average FLS vacancy rate was 22% across the state. By region, the average FLS vacancy rate was 18% in the East, 22% in the Middle, and 28% in the West.

Service Areas

This section of the report summarizes program participation within service areas, including (1) ECF CHOICES, (2) DIDD Waiver service, (3) Vocational Rehabilitation, and (4) CHOICES (Non-ECF CHOICES).

• CHOICES (Non-ECF CHOICES) (120): 78%
• ECF CHOICES (73): 47%
• DD Waiver (60): 39%
• Vocational Rehabilitation (17): 12%

Note: The number of responding organizations is in parenthesis. Percentages add to greater than 100 as organizations responded yes or no to each of the service areas.

As seen in Figure 17, of the 154 organizations, 78% provided CHOICES (Non-ECF CHOICES), 47% ECF CHOICES, 39% DIDD Waiver Service, and 12% Vocational Rehabilitation.

Service Types

Within each service area were multiple service types for a total of 17 programs across the four service areas. Organizations were asked to identify which services they provided out of these 17 service types. Of the 153 organizations who answered service types, all provided at least one service type. Forty-eight percent provided two or three service types, 16% provided four or five service types, and 17% provided between six and 10 service types. Eleven percent of organizations provided between 11 and 16 service types. One percent of organizations provided all 17 service types. What follows in the next section are findings for each service type separately.

ECF CHOICES Qualified Job Developer

As seen in Table 8, 38% of organizations providing ECF CHOICES services provided ECF Choices Employment Services Requiring a Qualified Job Developer. For the 12 organizations who answered, 1% (range 0% to 5%) of Caregivers/DSPs provided the majority of their services in this service type. For Caregivers/DSPs who provided Employment Services Requiring a Qualified Job Developer, the average starting wage was $14.16 and the average wage overall was $14.95.

ECF CHOICES Qualified Job Coach

Thirty-eight percent of organizations providing ECF CHOICES services provided ECF Choices Employment Services Requiring a Qualified Job Coach. For the 17 organizations who answered, 3% (range 0% to 13%) of Caregivers/DSPs provided the majority of their services in this service type. For Caregivers/DSPs who provided Employment Services Requiring a Qualified Job Coach, the average starting wage was $14.01 and the average wage overall was $14.76 (see Table 9).

ECF CHOICES Community Integration Support Services/Independent Living Skills Training

As seen in Table 10, 53% of organizations providing ECF CHOICES services provided ECF Choices Community Integration Support Services/Independent Living Skills Training. For the 21 organizations who answered, 1% (range 0% to 44%) of Caregivers/DSPs provided the majority of their services in this service type. For Caregivers/DSPs who provided Community Integration Support Services/Independent Living Skills Training, the average starting wage was $13.56 and the average wage overall was $14.14.

ECF CHOICES Community Living Supports (CLS)

Sixty-nine percent of organizations providing ECF CHOICES services provided ECF Choices Community Living Supports. For the 25 organizations who answered, 11% (range 0% to 43%) of Caregivers/DSPs provided the majority of their services in this service type. For Caregivers/DSPs who provided Community Living Supports, the average starting wage was $13.57 and the average wage overall was $14.21 (see Table 11).

ECF CHOICES Personal Assistance and/or Supportive Home Care

As seen in Table 12, 68% of organizations providing ECF CHOICES services provided ECF Choices Personal Assistance and/or Supportive Home Care. For the 29 organizations who answered, 33% (range 0% to 100%) of Caregivers/DSPs provided the majority of their services in this service type. For Caregivers/DSPs who provided Personal Assistance and/or Supportive Home Care, the average starting wage was $13.32 and the average wage overall was $13.95.

DIDD Waiver 1915c Employment Supports

Seventy-six percent of organizations providing DIDD Waiver Services provided 1915c Employment Supports. For the 24 organizations who answered, 3% (range 0% to 20%) of Caregivers/DSPs provided the majority of their services in this service type. For Caregivers/DSPs who provided 1915c Employment Supports, the average starting wage was $13.58 and the average wage overall was $14.26 (see Table 13).

DIDD Waiver 1915c Residential/Supported Living Services

As seen in Table 14, 90% of organizations providing DIDD Wavier Services provided 1915c Residential/Supportive Living Services. For the 31 organizations who answered, 57% (range 0% to 96%) of Caregivers/DSPs provided the majority of their services in this service type. For Caregivers/DSPs who provided 1915c Residential/Supportive Living Services, the average starting wage was $13.52 and the average wage overall was $14.23.

DIDD Waiver 1915c Personal Assistance Services

Seventy-eight percent of organizations providing DIDD Waiver Services provided 1915c Personal Assistance Services. For the 27 organizations who answered, 13% (range 0% to 100%) of Caregivers/DSPs provided the majority of their services in this service type. For Caregivers/DSPs who provided 1915c Personal Assistance Services, the average starting wage was $13.51 and the average wage overall was $14.19 (see Table 15).

DIDD Waiver 1915c Community Based Services

As seen in Table 16, 90% of organizations providing DIDD Wavier Services provided 1915c Community Based Services. For the 29 organizations who answered, 14% (range 0% to 100%) of Caregivers/DSPs provided the majority of their services in this service type. For Caregivers/DSPs who provided 1915c Community Based Services, the average starting wage was $13.44 and the average wage overall was $14.03.

DIDD Waiver 1915c Facility Based Services

Thirty-eight percent of organizations providing DIDD Waiver Services provided 1915c Facility Based Services. For the 11 organizations who answered, 5% (range 0% to 37%) of Caregivers/DSPs provided the majority of their services in this service type. For Caregivers/DSPs who provided 1915c Facility Based Services, the average starting wage was $13.52 and the average wage overall was $14.33 (see Table 17).

Vocational Rehabilitation: Qualified Employment Specialist

As seen in Table 18, 89% of organizations providing Vocational Rehabilitation provided Employment Services Requiring a VR-Qualified Employment Specialist. For the nine organizations who answered, 1% (range 0% to 4%) of Caregivers/DSPs provided the majority of their services in this service type. For Caregivers/DSPs who provided Employment Services Requiring a VR-Qualified Employment Specialist, the average starting wage was $14.18 and the average wage overall was $14.97.

Vocational Rehabilitation Qualified Job Coach

Eighty-nine percent of organizations providing Vocational Rehabilitation provided Employment Services Requiring a VR-Qualified Job Coach. For the nine organizations who answered, 1% (range 0% to 4%) of Caregivers/DSPs provided the majority of their services in this service type. For Caregivers/DSPs who provided Employment Services Requiring a VR-Qualified Job Coach, the average starting wage was $13.83 and the average wage overall was $14.98 (see Table 17).

CHOICES (Non-ECF CHOICES): Personal Care Services

As seen in Table 20, 90% of organizations providing CHOICES (Non-ECF CHOICES) provided Personal Care. For the 62 organizations who answered, 41% (range 0% to 100%) of Caregivers/DSPs provided the majority of their services in this service type. For Caregivers/DSPs who provided Personal Care, the average starting wage was $12.92 and the average wage overall was $13.54.

CHOICES (Non-ECF CHOICES): Attendant Care Services

Eighty-three percent of organizations providing CHOICES (Non-ECF CHOICES) provided Attendant Care. For the 52 organizations who answered, 41% (range 0% to 100%) of Caregivers/DSPs provided the majority of their services in this service type. For Caregivers/DSPs who provided Attendant Care, the average starting wage was $12.97 and the average wage overall was $13.54 (see Table 21).

CHOICES (Non-ECF CHOICES): Community Living Supports

As seen in Table 22, 27% of organizations providing CHOICES (Non-ECF CHOICES) provided Community Living Supports. For the 16 organizations who answered, 19% (range 0% to 100%) of Caregivers/DSPs provided the majority of their services in this service type. For Caregivers/DSPs who provided Community Living Supports, the average starting wage was $13.25 and the average wage overall was $14.23.

CHOICES (Non-ECF CHOICES): Adult Day Care

Ten percent of organizations providing CHOICES (Non-ECF CHOICES) provided Adult Day Care. For the 7 organizations who answered, 48% (range 0% to 100%) of Caregivers/DSPs provided the majority of their services in this service type. For Caregivers/DSPs who provided Attendant Care, the average starting wage was $13.58 and the average wage overall was $14.23 (see Table 23).

CHOICES (Non-ECF CHOICES): Respite

As seen in Table 24, 83% of organizations providing CHOICES (Non-ECF CHOICES) provided Respite. For the 44 organizations who answered, 12% (range 0% to 100%) of Caregivers/DSPs provided the majority of their services in this service type. For Caregivers/DSPs who provided Respite, the average starting wage was $12.81 and the average wage overall was $13.28.

Revenue & Authorized Services

Statewide, the average total annual revenue per organization was $7,240,666 (range $25,000 to $170,802,978). By region, the average total annual revenue was $6,571,291 (range $57,000 to $26,893,000) in the East, $11,277,131 (range $46,000 to $170,802,978) in the Middle, and $3,891,648 (range $25,000 to $50,000,000) in the West. On average, 84% of organizations’ total dollars statewide were authorized for services, and an average of 85% of the organizations’ total dollars for services were actually billed (i.e., authorized expenses billed). In the East, an average of 80% of total dollars were authorized for services, and 84% of the total dollars for services were actually billed. In the Middle, an average of 87% of total dollars were authorized for services, and 89% of the total dollars for services were actually billed. In the West, an average of 85% of total dollars were authorized for services, and 82% of the total dollars for services were actually billed.

Revenue & Worker’s Compensation from ECF CHOICES

Across the state, an average of 36% of overall revenue derived from ECF CHOICES rates was directed toward wages for Caregivers/DSPs. By region, 43% of revenue from ECF CHOICES rates were directed toward Caregiver/DSP wages in the East, 41% in the Middle, and 24% in the West. Statewide, an average of 1% of organizations’ overall revenue derived from ECF CHOICES rates was used for Caregiver/DSP worker’s compensation. By region, 1% of overall revenue from ECF CHOICES rates was used for Caregiver/DSP worker’s compensation in the East, 3% in the Middle, and 1% in the West.

Revenue & Worker’s Compensation from CHOICES (Non-ECF CHOICES)

Across the state, an average of 52% of overall revenue derived from CHOICES (Non-ECF CHOICES) rates was directed toward wages for Caregivers/DSPs. By region, 52% of revenue from CHOICES (Non-ECF CHOICES) rates were directed toward Caregiver/DSP wages in the East, 55% in the Middle, and 49% in the West. Statewide, an average of 2% of organizations’ overall revenue derived from CHOICES (Non-ECF CHOICES) rates was used for Caregiver/DSP worker’s compensation. By region, 2% of overall revenue from CHOICES (Non-ECF CHOICES) rates was used for Caregiver/DSP worker’s compensation in the East, 2% in the Middle, and 2% in the West.

Direct Support Professionals and Frontline Supervisors Trends Over Time

Examining trends over time was done differently in year 5. In the past, only organizations from the original year 1 sample frame who had all years of data were included. Over the years, there were fewer organizations who had all years of data, and with the addition of the aging and disabilities sector, results over time have become less representative of the original IDD workforce sample. So, the comparison is cohorts over time rather than the exact same organizations over time.

Caregiver/DSP average scores for turnover (sometimes referred to as crude separation rate), early turnover, vacancy rates, and hourly wages were examined to see how they changed over the five years. FLS average scores for turnover, early turnover, vacancy rates, and salaries were examined to see how they operated over four years. The questions about FLSs were not asked in the first survey.

CAUTION SHOULD BE EXERCISED WHEN INTERPRETING TRENDS OVER TIME THAT ARE PRESENTED BELOW.

While we can discuss outcome values increasing or decreasing, caution needs to be taken with interpretation as we do not have the data to empirically understand what factors influenced the changes. In addition to changes in samples over the years, other major unanticipated events influencing the data over the five years included a tornado outbreak in March 2020, the COVID-19 pandemic beginning in April 2020, and wage increases that were implemented beginning in Tennessee in 2021. Increasing access to HCBS, strengthening the HCBS workforce and building organization capacity were outlined in the Tennessee HCBS FMAP funding plan submitted and approved by the Centers for Medicare & Medicaid Services (CMS; Moss, 2022). The pandemic affected organization functioning, specifically staffing and wages with augmentations. These events had an impact on 2020, 2021 and 2022 data although the degree of effect is not known.

Caregiver/Direct Support Professionals Trends Over Time

Caregiver/DSP Retention Rates

Four measures of retention were computed and examined for Caregiver/DSPs. These included: annual turnover, early turnover within 0-6M of hire, turnover within 6-12M of hire, and vacancy rate.

Annual Caregiver/DSP turnover tells the percentage of Caregiver/DSPs who left the organization (turned over) in the last year out of all Caregiver/DSP positions. As seen in Figure 18, the average annual turnover in surveyed organizations was 46% in 2018, 47 in 2019, 63% in 2020, 57% in 2021, and 61% in 2022.

Early Caregiver/DSP turnover within 0-6 months of hire tells the percentage of Caregiver/DSPs who left their position within the first 6 months of starting the job. For Caregiver/DSPs, the average early turnover within 0-6 months of hire was 53% in 2019, 47% in 2020, 57% in 2021, and 61% in 2022.

Caregiver/DSP turnover within 6-12 months of hire tells the percentage of Caregiver/DSPs who left their position within 6-12 months of starting the job. For Caregiver/DSPs, the average turnover within 6-12 months of hire was 33% in 2019, 32% in 2020, and 28% in 2021 and 2022.

Caregiver/DSP vacancy rate tells the percentage of vacant positions out of all of the Caregiver/DSP positions. The average Caregiver/DSP vacancy rate was 15% in 2018, 13% in 2019, 19% in 2020, 21% in 2021, and 17% in 2022.

	2018	2019	2020	2021	2022
turnover	46%	47%	63%	57%	61%
early turnover (0-6 months)		53%	47%	57%	61%
turnover in first year (6-12 months)		33%	22%	28%	28%
vacancy	15%	13%	19%	21%	17%

Note: 2018: Turnover and Vacancy N=42; 2019: Turnover and Vacancy N=69; 2020: Turnover N=55 and Vacancy N=56; 2021: Turnover N=106 and Vacancy N=108; 2022: Turnover N=132 and Vacancy N=134.

Caregiver/DSP Hourly Wages

Organizations provided data for Caregiver/DSP starting hourly wages, average hourly wages, and highest hourly wages. As seen in Figure 19, the average Caregiver/DSP starting hourly wage was $9.38 in 2018, $9.88 in 2019, $10.36 in 2020, $12.05 in 2021, and $13.21 in 2022. The average Caregiver/DSP hourly wage was $10.17 in 2018, $10.56 in 2019, $11.09 in 2020, $12.60 in 2021, and $13.69 in 2022. The average Caregiver/DSP highest hourly wage was $12.22 in 2018, $13.11 in 2019, $13.20 in 2020, $14.47 in 2021, and $14.95 in 2022.

	2018	2019	2020	2021	2022
starting hourly wage	$9.38	$9.88	$10.36	$12.05	$13.21
hourly wage	$10.17	$10.56	$11.09	$12.60	$13.69
highest hourly wage	$12.22	$13.11	$13.20	$14.47	$14.95

Note: 2018: n=46; 2019: n=71; 2020: n=61; 2021: n=122; 2022: n=136.

Frontline Supervisor Retention Rates

Four measures of retention were computed and examined for FLSs. These included: annual turnover, early turnover within 0-6M of hire, turnover within 6-12M of hire, and vacancy rate. These were not asked until year 2 (2019).

Annual FLS turnover tells the percentage of FLSs who left the organization (turned over) in the last year out of all of the FLS positions. Early FLS turnover within 0-6 months of hire tells the percentage of FLSs who left their position within 0-6 months of starting the job. FLS turnover within 6-12 months of hire tells the percentage of FLSs who left their position within 6-12 months of starting the job. FLS vacancy rate tells the percentage of vacant positions out of all of the FLS positions.

As seen in Figure 20, the average FLS annual turnover was 25% in 2019, 21% in 2020, 41% in 2021, and 30% in 2022. The average early turnover within 0-6 months of hire was 29% in 2019, 23% in 2020, 28% in 2021, and 35% in 2022. The average turnover within 6-12 months of hire was 28% in 2019, 29% in 2020, 51% in 2021, and 46% in 2022. The average vacancy rate was 13% in 2019, 16% in 2020, 15% in 2021, and 22% in 2022.

	2019	2020	2021	2022
turnover	25%	21%	41%	30%
early turnover (0-6 months)	29%	23%	28%	35%
turnover (6-12 months)	28%	29%	51%	46%
vacancy rate	13%	16%	15%	22%

Note: 2019: Turnover N=57 & Vacancy N=56; 2020: Turnover N=53 & Vacancy N=50; 2021: Turnover N=90 & Vacancy N=86; 2022: Turnover N=96 & Vacancy N=99.

Frontline Supervisor Salaries

Organizations provided data for FLS starting salary, annual salary, and highest salary. As seen in Figure 21, the average FLS starting salary was $31,187 in 2019, $31,552 in 2020, $34,180 in 2021, and $37,177 in 2022. The average FLS annual salary was $34,670 in 2019, $34,024 in 2020, $36,611 in 2021, and $39,469 in 2022. The average FLS highest salary was $42,654 in 2019, $38,731 in 2020, $43,629 in 2021, and $44,797 in 2022.

	2019	2020	2021	2022
starting salary	$31,187	$31,552	$34,180	$37,177
annual salary	$34,670	$34,024	$36,611	$39,469
highest salary	$42,654	$38,731	$43,629	$44,797

Note: 2019: n=65; 2020: n=55; 2021: n=103; 2022: n=117.

Summary of Caregiver/Direct Support Professional and Frontline Supervisor Trends Over Time

As a reminder, CAUTION SHOULD BE EXERCISED WHEN INTERPRETING TRENDS OVER TIME PRESENTED IN THIS REPORT.

While none of the trends in retention measures or wages and salaries can be directly attributed to involvement in specific training and consultation activities, there are trends worth noting, especially considering the pandemic in 2020 that persisted through 2022. An additional reminder with interpreting trends over time is that the sample changed annually. Results for each survey year are for those organizations that responded in a given year. This is important as there was a substantial change to the sample in 2021 when the study expanded to include CHOICES (Non-ECF CHOICES) organizations.

For Caregiver/DSPs, prior to the pandemic (2018-2019), annual turnover was consistent at 46% and 47% but rose to 61% in 2022. Early turnover within 0-6 months went up over time (53% in 2019 to 61% in 2022) while turnover within 6-12 months of being hired went down and leveled off (33% in 2019 to 28% in 2021 and 2022). Caregiver/DSP vacancy increased from 15% in 2018 to 21% in 2021 but declined to 17% in 2022. Starting, hourly and highest wages increased annually for Caregiver/DSPs.

For FLSs, turnover increased from 25% in 2019 to 41% in 2021 but decreased to 30% in 2022. Early turnover within 0-6 months of hire decreased initially from 29% in 2019 to 23% in 2020 but increased thereafter to 35% in 2022. For turnover within 6-12 months of hire, rates were consistent in 2019 and 2020 (28%, 29%), increased to 51% in 2021, and decreased to 46% in 2022. FLS vacancy rates have increased from 13% in 2019 to 22% in 2022. FLS starting, annual, and highest salaries increased annually.

Discussion

Workforce Instability

A competent, stable direct support workforce is imperative for the delivery of home and community-based services for people with disabilities and seniors to access, live, and work in the community. Unfortunately, there is a widespread, long-term incidence of vacancy rates and high turnover among the direct support workforce (Scales, 2020). Organizations in Tennessee continue to face difficulties in recruiting, hiring, and retaining ample Caregivers/DSPs to meet this demand. There was a 61% Caregiver/DSP turnover rate (Figure 13), and a 17% vacancy rate (Figure 12) in 2022. This means that over half of the Caregiver/DSP workforce left their positions in 2022, and nearly one out of every five Caregiver/DSP positions were vacant. These are both higher than national rates for DSPs: the DSP turnover rate was 43.3% and the vacancy rate for full-time staff was 16.5% and for part-time staff was 20.3% (National Core Indicators Intellectual and Developmental Disabilities, NCI-IDD, 2022). The result in Tennessee is uncertain and inadequate services for people with disabilities and seniors and pronounced challenges for organizations that employ Caregivers/DSPs to create a stable organizational culture that supports Caregivers/DSPs. Additionally, the COVID-19 pandemic also impacted staffing and the delivery of services to people (Hewitt, Pettingell, Bershadsky, et al., 2021; Pettingell, Bershadsky, et al., 2022). This was reinforced by participating organizations who shared stories of the unprecedented challenges they were continuing to face in finding and keeping Caregivers/DSPs.

Staff turnover is very costly for organizations. A typical rule of thumb for estimating costs related to turnover is that costs related to exiting an employee and replacing that position are about 25% of the annual salary of the position (Anderson-Hoyt et al., 2010). Organizations in this study reported a total of 11,311 Caregivers/DSPs employed in 2022. Using the 25% of the Caregiver/DSP annual salary rule of thumb for cost of turnover and the average overall Caregiver/DSP wage of $13.69 per hour (Figure 8), costs of each Caregiver/DSP who leaves the position may be $7,118.80. At the rate of $7,118.80 per Caregiver/DSP, a 61% Caregiver/DSP annual turnover rate in the state of Tennessee results in an estimated $49,117,655 in costs related to Caregiver/DSP turnover. Eliminating even half of these costs could result in an annual $2,172 bonus per Caregiver/DSP for the 11,311 Caregivers/DSPs reported.

Many Caregivers/Direct Support Professionals Leave Their Positions Soon After Hire

Of the 61% of Caregivers/DSPs who left their positions in 2022, 61% left in the first six months of employment. Another 28% of those who left their positions left within six to twelve months of employment (Figure 13). This is a high rate of Caregivers/DSPs leaving their position soon after starting, particularly for providing the skilled, personalized supports required of many Caregivers/DSPs. For comparison, in organizations that employ DSPs in 29 states including the District of Columbia, 35.1% of DSPs who left their jobs in 2021 left in the first six months, and 21.0% left in 6-12 months tenure (NCI-IDD, 2022).

High rates of Caregivers/DSPs leaving in 0-6 months or 6-12 months of hire can indicate the need for organizations to provide additional training and supports to new staff on the job, as well as job feedback in order to develop sufficient skills on the job. It may also signal that job candidates are entering these positions without clear expectations about what the job entails. Without access to clear job descriptions or a realistic job preview prior to hire, some candidates may be hired who are unaware of what will be required of them on the job. These candidates may find that this work is not a good fit for them soon after starting. Others may leave if there is work available in another industry for similar or better pay.

In Tennessee, organizations had access to resources through the TN DSP workforce toolkit, training and consultation to assist them in reviewing their current practices that are known to influence turnover in the first six months of hire. Training and technical assistance was available and provided by MCO’s workforce coaches. Some of the topics covered through recorded webinars and web-based TN DSP workforce toolkit include hiring practices and using referral bonuses in recruitment, ease of applying through the organization website, sample job descriptions that align with core competencies, structural behavioral interview guides, realistic job preview and how to incorporate into the selection process, effective orientation, onboarding and peer mentoring and the importance of effective frontline supervision in the first six months along with other training topics and resources. Organizations having the goal of reducing their early turnover (within 6 months of hire) who maintain efforts to implement what they have learned can measure the impact of turnover over time.

Pervasive Vacancy Rates Influencing Recruitment and Retention

Vacancy rates is a key indicator in measuring workforce stability (NCI-IDD, 2022). With historically high rates for this workforce sector, increases in vacancy rates have a corresponding effect on outcomes for people who rely on these services for support in their daily lives. In addition, when adequate DSP staffing cannot be secured and given the essential support services provided by these workers, existing workers are often asked to work long hours which is more likely to lead to burnout over time (Gray-Stanley, 2011; Vassos & Nankervis, 2012). The demand by people eligible for long term services and supports cannot be met without an adequate supply of DSPs and FLSs (Campbell et al., 2021). In Tennessee, vacancy rates for Caregivers/DPSs in 2022 was 17% (see Figure 12). The 2022 vacancy rate signals a pervasive problem with recruiting and retaining enough Caregivers/DSPs to meet the growing demand for long term services and supports. It also likely demonstrates the damaging impact COVID-19 has had on HCBS provider organizations regarding their workforce. Of equal importance is the vacancy rate for FLSs in Tennessee. The overall vacancy rate for FLSs in 2022 was 22% (see Figure 16).

Low Wages and Limited Benefits

Organizations reported starting and average wages paid to Caregivers/DSPs. Average starting hourly Caregiver/DSP wages were $13.21 per hour. The state average Caregiver/DSP wages were $13.69 per hour. These wages are lower when compared to nationwide trends. The average starting and average hourly wages for DSPs nationwide in 2022 were $13.61 and $14.41, respectively (NCI-IDD, 2022). The average Caregiver/DSP who works 2,000 hours per year would gross only $27,280. The poverty line for a family of three in 2021 was $23,030 (Office of the Assistant Secretary for Planning and Evaluation, APSE, 2023). The average Caregiver/DSP supporting a household is set squarely in the working poor with these wages paid, and eligible for public assistance in programs that utilize the federal poverty line as a threshold. Multiple studies have demonstrated the relation between wages and DSP turnover rates. Organizations that pay higher wages have lower turnover rates (Pettingell, Houseworth, et al., 2022; Houseworth et al., 2020; Anderson-Hoyt et al., 2010). Some organizations have attempted to provide bonuses and incentives to Caregivers/DSPs when they meet certain benchmarks determined by the organization such as longevity, training, and performance. If funds allowed, this strategy could be modified with a larger wage increase or the wage increase happening earlier in the Caregivers/DSPs tenure. Using a career ladder or credentialing model such as the NADSP e-Badge Academy to provide incentives for professional development may influence the trajectory of this continued low wage trend.

Access to benefits is another important factor in keeping Caregivers/DSPs in their jobs. Access to both paid time off and health insurance are additional measures that can increase Caregiver/DSP tenure, particularly in the face of a job market growing increasingly competitive. Only 40% of organizations offered paid time off to some or all of their Caregivers/DSPs; 11% offered paid sick leave and 18% offered paid vacation to some or all of their Caregivers/DSPs (Table 6). Direct support is difficult, and one of the highest rates of injury professions in the nation (Bureau of Labor Statistics, 2020). Additionally, the stresses of living in poverty, can make it difficult for Caregivers/DSPs to persist in this work without access to paid leave and other benefits such as health insurance. Examining and improving paid leave policies is another strategy for supporting this workforce.

Fifty-five percent of organizations reported offering health insurance to some or all of their Caregivers/DSPs. However, for organizations that offered health insurance, an average of only 27% of Caregivers/DSPs used the benefit. Organizations reported that the average cost of health insurance for an individual Caregiver/DSP was $142 per month, with average costs more than doubling for single plus 1 and family coverages (Table 7). The cost of health insurance may simply be too high for Caregivers/DSPs to afford the benefit alongside other costs of living. If this is the case, more affordable options need to be explored. In a study of over 1,400 provider agencies who completed the National Core Indicators 2016 Staff Stability Survey, provision of paid time off and health insurance to DSPs was a predictor of lower turnover rates (Houseworth et al., 2020). Exploring ways to provide these benefits may provide cost savings to organizations by reducing Caregiver/DSP turnover.

Cost of Overtime

An important workforce issue for organizations is the level of Caregiver/DSP overtime hours and money paid out for overtime. Organizations reported overtime hours paid to Caregivers/DSPs in 2022. Across the state, the average number of overtime hours that organizations paid out to Caregivers/DSPs in 2022 was 18,600 hours (range 0 to 332,852), and the total number of overtime hours paid out in 2022 was 2,399,338 hours (Figure 10). The average cost of Caregiver/DSP overtime in 2022 was $140,135 (range $0 to $2,466,433), and the total cost of Caregiver/DSP overtime in 2022 was $17,100,135 (Figure 11). Reducing overtime costs by filling vacancies allows organizations the opportunity to reallocate cost savings to other areas of need to address workforce recruitment and retention such as increasing wages, enhanced benefits or professional development. When organizations are able to pay more to Caregivers/DSPs, relationships with people supported remain stable and burnout and turnover may even be reduced.

Access to Support from Frontline Supervisors

Another common reason Caregivers/DSPs report leaving their positions is due to lack of support or the poor quality of support from Frontline Supervisors (FLSs) (Hewitt et al., 2019). FLSs are a critical source of Caregiver/DSP support and training on the job. Competent FLSs can improve the retention of Caregivers/DSPs. Without sufficient support, Caregivers/DSPs may feel less equipped to do their work and more prone to seeking other employment. Turnover and vacancy rates among FLSs also contribute to instability of the Caregiver/DSP workforce. Thirty percent of FLSs left their positions in 2022, with 35% of those Frontline Supervisors leaving within 0-6 months of hire (Figure 15). There was a 22% vacancy rate in FLSs statewide (Figure 16). Further exploration and analysis about the reasons why FLSs leave their position is warranted and could provide valuable insight. Another opportunity for consideration is how the National Frontline Supervisor Core Competencies align with current training for FLSs in Tennessee. Competency-based curriculum that focuses on supporting and training FLSs, such as the College of Frontline Supervision, Management and Leadership or other training focused on frontline supervision, may offer a promising strategy for helping FLSs increase their knowledge, skills and abilities needed to be effective supervisors (DirectCourse, 2021). Improving support and training of FLSs can result in better communication, engagement and recognition of Caregivers/DSPs in addition to reducing Caregiver/DSP turnover.

Persistent Workforce Issues Across Regions and Service Types

Organizations reported their data across regions and service types, but regional data was difficult to interpret in some cases due to low sample size. In most cases, regional differences were slight, indicating that workforce issues persist across all regions in the state. Some differences may be the result of geographic or market differences or the cost of living being higher in certain regions. Furthermore, the COVID-19 pandemic may have affected certain regions of the state differently throughout 2022. Several pieces of data were collected across 17 service types, but many organizations reported that it was difficult or impossible to delineate data across the service types. Participating organizations indicated that 55% of Caregivers/DSPs provide services across service types, and most organizations (89%) pay Caregivers/DSPs the same wages when they work across service types (98% for the East region, 76% in the Middle region, and 94% for the West region).

Recommendations

Survey and Data Collection

To monitor trends in the direct support workforce related to turnover and vacancy rates as well as wages, it is critical to continue to understand the sample, improve its representativeness and gather good quality data. It will be important for the MCOs and TennCare to ensure adequate resources are available for survey development and implementation, data collection, and ongoing analyses.

It is important to reflect on and consider the sample composition. There are two groups of interest included in the year five sample: the original organizations supporting primarily the ECF CHOICES population from the first three years of the initiative and the identified organizations supporting primarily the CHOICES (Non-ECF CHOICES) population from the aging and disability sector added in year four.

To accurately describe and understand workforce issues, a representative sample of the organizations providing supports to these populations needs to continue to be developed. The first three years of the survey had the same sample of organizations supporting primarily the ECF CHOICES populations. With the addition of organizations supporting primarily the CHOICES (Non-ECF CHOICES) population in year 4, the composition of the sample changed. The MCOs are working toward this with the goal of adding organizations over time. To aid in their efforts, it is a good time to revisit and refine explicit eligibility criteria for participating provider organizations. While building a representative and stable sample takes time, it is important and will allow trends over time to be examined with confidence.

Data collection is a time-consuming and vital part of this process. It is important that the data collection team is large enough that tasks happen efficiently and effectively. This includes taking time prior to survey launch to verify that all organizations meet the eligibility criteria to participate and ensure accurate contact information of one person as the primary survey/data collection contact. Once the survey is launched, follow-up with organizations needs to be persistent and thorough. That requires making contact with all participating organizations and establishing lines of communication at the onset of the data collection period. Follow-up with organizations who have not submitted their surveys also needs to be consistent and regular, verifying that the contact received the survey, answering their questions about the survey, reminding them of the importance of their voice, and encouraging them to complete the survey on time. Establishing and fostering relationships with the organizations so they understand and feel the importance of their data contribution is one of the key factors influencing organizations to participate.

At the end of the data collection period, it is important to review the survey to confirm the data needed are adequately captured in the survey questions as well as verify the survey administration format best fits the needs of the participants to ensure quality data are collected.

Lastly, in order to better understand change in trends over time, when implementing statewide recruitment and retention strategies such as the NADSP e-badge or Apprenticeships programs, it is worth considering the development of a system that tracks and connects implementation of strategies to workforce data at the organizational level. Identifying new trends could provide valuable information to TennCare and MCOs in their ongoing efforts in data-driven decision-making when responding to Tennessee's workforce challenges. Items to track could include metrics such as what training initiative(s) have been implemented, the date they were implemented, the amount of time spent using technical assistance around each of the initiatives, etc. The UMN could assist the MCOs with identifying what metrics are of most importance and how to set up and monitor collection of this data. When this type of information about strategy implementation is captured in the data, this information can provide context for explaining trends and changes in outcomes.

Ongoing Support for Provider Organizations in Workforce Development

It is important to continue to support capacity-building activities through MCO workforce development efforts at the organization level. It is essential that MCO workforce efforts continue to provide opportunities for targeted ongoing training and technical assistance using workforce data to address workforce challenges for organizations across the state. By providing targeted technical assistance to organizations using best practices in workforce development and tracking these efforts, TennCare and MCOs can continue to monitor progress in addressing turnover, vacancies and tenure at the organizational level. Providing individualized technical assistance to organizations can reinforce their understanding of the importance of accuracy in the tracking, collecting and reporting of their workforce data and the value of continuing to participate in the annual survey. One of the goals of technical assistance is to help organizations understand their workforce data and to connect implementation of workforce strategies to key data points to gauge their effectiveness.

Previously, organizations in Tennessee preferred participating in training offered in different ways including individualized consultation with workforce consultants and coaches, webinars, learning labs, office hours at organization level, and through communities of practice with their peers at regional and state levels. Using a diverse set of options to support organizations in implementing workforce development strategies in a systematic way, such as those listed above, is important to continue in Tennessee. Providing financial incentives to organizations that tie implementation of evidence-based and best practices in recruitment and retention with specific workforce and quality of life outcomes could increase the number of organizations interested in seeking support with recruitment and retention efforts.

Implementation of Competency-Based Training and Wage Incentives Model

Competency-based training is a retention technique for Caregivers/DSPs to become competent and confident in their jobs. Continuing to work with organizations and Caregivers/DSPs to understand what training is needed to improve Caregiver/DSP knowledge, skills and abilities to be successful in their jobs and using this feedback to inform processes for developing and implementing a statewide competency-based training and wage incentives model is an important strategy to develop competent employees. In addition to exploring expansion of the Direct Support Professional Apprenticeship for developing a workforce pipeline for DSPs currently being implemented, developing a multi-level career ladder or credentialing program tied to wage increases could improve Caregiver/DSP skills, increase quality of services, and reduce turnover. During 2023, TennCare and MCOs announced that all Home and Community Based Service (HCBS) provider organizations in Tennessee (i.e., CHOICES, ECF CHOICES, 1915c, and Katie Beckett) can now participate in the NADSP E-Badge Academy. This initiative is for both DSPs and Frontline Supervisors. This current implementation of the NADSP e-Badge Academy presents an opportunity for Tennessee to measure the impact of this effort on reducing turnover.

Stakeholder engagement is essential when developing and implementing new workforce initiatives. Tennessee has several strong stakeholder groups advising in their workforce development efforts. Engaging this group is important. It is also important that any new initiative such as a credentialing program include an evaluation plan to gather key information for understanding what is working and not working with regard to implementing a career ladder or credentialing program. A well-executed evaluation plan can provide valuable individual and organizational data that can be aggregated and used to identify trends recruitment and retention at the regional and state levels.

Invest in Competency-Based Training for Frontline Supervisors

A well-trained and well-supported FLS can help support Caregivers/DSPs in their positions, reducing turnover and improving work satisfaction in both positions. Frontline Supervisor (FLS) turnover decreased from 41% in 2021 to 30% in 2022; however, vacancy rates continue to be high in Tennessee, indicating a need for further training for FLSs. Nationwide, Caregivers/DSPs are often promoted to Frontline Supervisors with little to no training, and often are not provided with sufficient support or time for continued training or professional development.

Currently in Tennessee, training for FLSs is organization-specific. HCBS provider organizations now have access to the NADSP E-Badge academy, presenting an opportunity for FLSs to have specific competency-based training. Additionally, the TN DSP Workforce Toolkit includes resources on National Frontline Supervisor Competencies as well as strategies for using these in developing competency-based training for frontline supervisors. Other resources include The College of Frontline Supervision, Management and Leadership, a national competency-based training curriculum for FLSs. It is important for Tennessee to review current training practices for FLSs and explore investing resources to support implementation of a competency-based training model for FLSs.

Provide Targeted Support to Organizations to Implement New Statewide Tools to Recruit and Select New Populations to the Workforce

There is still a need to attract new people to the Caregiver/DSP workforce. Additionally, early turnover within the first six months has increased over time; however, it is notable that in 2021, early turnover for part-time DSPs began a trend downward suggesting that recent statewide efforts to support recruitment may be contributing to this decrease in turnover for part-time DSPs. TennCare, in partnership with the University of Minnesota, created public service announcements and targeted marketing tools directed at new applicants entering the workforce. These tools need to continue to be utilized across Tennessee in a coordinated effort to recruit new people to the field. Public service announcements and targeted marketing flyers can be used in recruitment campaigns across the state at multiple levels and in various settings. During 2022, a Tennessee-specific realistic job preview was made available for organizations to use and incorporate into their hiring and selection processes. This has been the top viewed video on the TennCare YouTube Channel. As of October 1, 2023, full lifetime of the video included: 23,800 impressions with 2,751 views. During Direct Support Professional Appreciation in September 2023, there were 2,830 impressions (38% increase over the previous 28-day period) and 303 views (15% increase over the previous 28-day period). Organizations should continue to be coached and trained to incorporate realistic job previews into their hiring and selection processes to encourage applicants to get a better understanding of the role of Caregiver/DSP and ensure the job is right for them before embarking on a new career.

Coordinating the implementation of these tools in a systematic and coordinated way can reduce turnover and vacancy rates in Tennessee. These resources are available in the TN DSP Workforce Toolkit. Organizations would benefit from targeted training and ongoing support to help them develop an implementation plan to use these tools and measure their effectiveness in improving recruitment and retention of their workforce.

Conclusion

This survey is part of a comprehensive workforce initiative to better understand workforce recruitment and retention challenges in Tennessee. This fifth annual survey report includes important findings to inform data-driven solutions at the state and regional levels to support organizations in their efforts to recruit, hire, and retain Caregivers/DSPs. These data, especially when paired with training and consultation on workforce solutions where available to participating organizations, are intended to address the workforce crisis when implemented with fidelity over time. Organizations that participate are well-positioned to see a more stable and highly trained workforce over time. This report provides an additional insight into the status of the Caregiver/DSP workforce issues among the 154 participating organizations across the state of Tennessee.

References

• Anderson-Hoyt, J., McGee-Trenhaile, M., & Gortmaker, V. (2010). Direct Support Professional Wage Study: 2009. Alexandria, VA: ANCOR.
• Bureau of Labor Statistics. (2020). Employer-Reported Workplace Injuries and Illnesses – 2019 (USDL-20-2030). U.S. Department of Labor, 9. https://www.bls.gov/news.release/pdf/osh.pdf
• Campbell, S., Del Rio Drake, A., Espinoza, R., & Scales, K. (2021). Caring for the Future: The Power and Potential of America’s Direct Care Workforce. PHI. https://www.phinational.org/resource/caring-for-the-future-the-power-and-potential-of-americas-direct-care-workforce/
• DirectCourse. (2021). College of Direct Support/College of Frontline Supervision and Management. https://directcourseonline.com/
• Friedman, C. (2018). Direct Support Professionals and Quality of Life of People With Intellectual and Developmental Disabilities. Intellectual and Developmental Disabilities, 56(4), 234–250. https://doi.org/10.1352/1934-9556-56.5.234
• Friedman, C. (2020). The Impact of Ongoing Staff Development on the Health and Safety of People with Intellectual and Developmental Disabilities. Journal of Developmental and Physical Disabilities, 33(2), 181–196. https://doi.org/10.1007/s10882-020-09743-z
• Friedman, C. (2021). The Impact of Direct Support Professional Turnover on the Health and Safety of People With Intellectual and Developmental Disabilities. Inclusion, 9(1), 63–73. https://doi.org/10.1352/2326-6988-9.1.63
• Gray-Stanley, J. A., & Muramatsu, N. (2011). Work stress, burnout, and social and personal resources among direct care workers. Research in Developmental Disabilities, 32(3), 1065–1074. https://doi.org/10.1016/j.ridd.2011.01.025
• Hewitt, A., Pettingell, S., Bershadsky, J., Smith, J., Kleist, B., Sanders, M., Zhang, A., Dean, K., & Kramme, J. (2021). Direct Support Workforce and COVID-19 Survey: Providing Support During the COVID-19 Pandemic: Twelve Month Follow Up. Institute on Community Integration, University of Minnesota. https://ici.umn.edu/covid19-survey
• Hewitt, A., Pettingell, S., & Kramme, J. (2019). Minnesota Direct Support Worker Survey 2019: Final report. Institute on Community Integration, Research and Training Center on Community Living. https://ici.umn.edu/products/view/kfpN9PofQGWQNrV3FwsfeA
• Houseworth, J., Pettingell, S., Kramme, J., Tichá, R., & Hewitt, A. (2020). Predictors of annual and early separations among direct support professionals: National Core Indicators Staff Stability Survey. Intellectual and Developmental Disabilities, 58(3), 192–207.
• Larson, S. A., Tolbize, M. S. A., Kim, O., & York, B. (2016). Direct Support Professional Turnover Costs in Small Group Homes: A Case Study. Minneapolis: University of Minnesota, Research and Training Center on Community Living.
• Moss, K. (2022). Wage Increases for Frontline HCBS Workers in Employment and Community First CHOICES. Division of TennCare. https://www.tn.gov/content/dam/tn/tenncare/documents/July12022ECFRateMemoFINAL.pdf
• National Core Indicators Intellectual and Developmental Disabilities [NCI-IDD]. (2022). National Core Indicators Intellectual and Developmental Disabilities 2021 State of the Workforce Survey Report. https://idd.nationalcoreindicators.org/survey-reports-insights/
• Office of the Assistant Secretary for Planning and Evaluation [APSE]. (2023). Prior HHS poverty guidelines and federal register references. https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines/prior-hhs-poverty-guidelines-federal-register-references
• Pettingell, S., Bershadsky, J., Hewitt, A., Lahti Anderson, L., Hall, S., Smith, J., Sanders, M., Kleist, B., Zhang, A., & Oteman, Q. (2022). Direct Support Workforce and COVID-19 National Survey Report: 24-month Follow-up. Minneapolis: Institute on Community Integration, University of Minnesota.
• Pettingell, S. L., Houseworth, J., Tichá, R., Kramme, J. E. D., & Hewitt, A. S. (2022). Incentives, Wages, and Retention Among Direct Support Professionals: National Core Indicators Staff Stability Survey. Intellectual and Developmental Disabilities, 60(2), 113–127. https://doi.org/10.1352/1934-9556-60.2.113
• PHI. (2023). Direct Care Workers in the United States: Key Facts. PHI. https://www.phinational.org/resource/direct-care-workers-in-the-united-states-key-facts-2023/
• President’s Committee for People with Intellectual Disabilities [PCPID]. (2017). Report to the President 2017: America’s Direct Support Workforce Crisis: Effects on People with Intellectual Disabilities, Families, Communities and the U.S. Economy. Washington D.C. https://www.acl.gov/sites/default/files/programs/2018-02/2017%20PCPID%20Full%20Report_0.PDF
• Scales, K. (2020). It’s time to care: A detailed profile of America’s direct care workforce. PHI. https://phinational.org/resource/its-time-to-care-a-detailed-profile-of-americas-direct-care-workforce/
• Spreat, S. (2021). Direct Support Professional Vacancies in the IDD Field: A Study Over Time. International Journal of Economics, Business, and Management Research, 5(5), 274–282.
• Vassos, M. V., & Nankervis, K. L. (2012). Investigating the importance of various individual, interpersonal, organisational and demographic variables when predicting job burnout in disability support workers. Research in Developmental Disabilities, 33(6), 1780–1791. https://doi.org/10.1016/j.ridd.2012.04.016