Employment and Community First CHOICES Workforce QuILTSS Initiative Survey 2021: Year Four Report

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 (QuILTSS) Workforce Initiative 2021 Survey, analyze the data, and report the results.

This survey is a continuation of TennCare’s Quality Improvement in Long-Term Services and Supports (QuILTSS) Initiative project 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 survey has been a key component of a comprehensive workforce strategy in the Quality Improvement in Long-Term Services and Supports (QuILTSS) Initiative. As part of this comprehensive effort, data gathered 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. During the 3-year initiative, participating organizations received a data summary about the direct support workforce in their organization. Participating organizations also 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.

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

Project technical assistance team from the University of Minnesota included: Barbara Kleist, Sandra Pettingell, Megan Sanders, Chet Tschetter, Quinn Oteman, and Alicia Zhang.

Suggested citation:

• Pettingell, S., Kleist, B., Sanders, M., Zhang, A., & Oteman, Q. (2022). QuILTSS Workforce Initiative Survey 2021 Year Four Report. 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

Caregivers/Direct support professionals (DSPs) provide critical supports for people with disabilities and seniors so that they can live, work, and be fully engaged in their community. Caregivers/DSPs are employees who spend at least 50% of their time providing direct support to people with disabilities and seniors such as: personal care, home care, supervision, training, community integration, and employment supports. Caregivers/DSPs may perform a few supervisory tasks, but the focus of their job is direct support work. There are many job titles that represent Caregivers/DSPs, including caregiver, DSP, direct care worker, family model provider (FMP), residential aide, life skills instructor, job coach, home health aide, personal care assistant, and others. Nursing and other professional licensed staff (e.g., LPNs and RNs) and on-call staff (i.e., those who do not have any regularly scheduled hours) are not considered Caregivers/DSPs.

Caregiver/Direct Support Professional (DSP): An employee whose primary responsibilities includes providing personal assistance, support, training, and supervision to people with disabilities and seniors. They 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.

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 4.7 million workers in 2021, and it is expected to grow to include another 1.2 million workers by 2030 (PHI, 2022). 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 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). 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 and seniors who experience greater Caregiver/DSP turnover have more injuries and instances of abuse and neglect. The health and safety of people with 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 provider, program, and state level comprehensive workforce data to identify and match interventions to recruit and retain Caregivers/DSPs in organizations that provide services and supports to people with IDD, disabilities, and seniors. Interventions 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). In order to positively impact the workforce crisis, organizations need to learn skills to improve their recruitment, selection, and retention of DSPs (PCPID, 2017). This includes assessing and responding to the added burden placed on an already unstable workforce by COVID-19. This global pandemic was declared by the World Health Organization in March of 2020, impacting the delivery of services to people receiving long term services and supports and the Caregivers/DSPs who support them. In fact, aging and having an intellectual disability are two of the strongest risk factors for dying from the COVID-19 pandemic (Gleason et al., 2021). This places human service organizations and Caregivers/DSPs in an integral role in supporting health and safety in the midst of the pandemic.

In the past year, several studies were initiated to address the impact COVID-19 is having on the workforce. In a 2020 survey of over 1,600 community provider organizations in all fifty states and the District of Columbia who provide long term services and supports for people with IDD, 68% reported closure of one or more services due to the COVID-19 pandemic (Avalere, 2020). This resulted in an average 32% loss of revenue. Organizations also experienced significant staffing challenges. In a series of four surveys of over 8,800 respondents from nearly all 50 states, DSPs and FLSs reported differences in staffing and schedules since the start of the pandemic (Hewitt et al., 2020; Hewitt et al., 2021a, Hewitt et al., 2021b; Pettingell et al., 2022). Forty-four percent reported working more hours, 43% have different work responsibilities or roles, 35% work different shifts, and 28% worked in different settings since the start of the pandemic. While adequate staffing was a widespread issue among organizations that employ DSPs and FLSs before the pandemic, only 55% of DSPs and FLSs indicated that the locations where they worked were adequately staffed during the pandemic (Hewitt et al., 2020). In 2021, 60% reported working more hours, 68% had different work responsibilities or roles, 45% worked different shifts, and 40% worked in different settings since the start of the pandemic. Although 72% of DSPs and FLSs indicated that new staff had been hired in the past six months, 39% said the new staff were qualified to do the work, but 52% said only some were qualified to do the work and 9% said they were not qualified to do the work (Pettingell et al., 2022). The impact of the COVID-19 pandemic on the direct support workforce is continuing to be assessed as organizations carry out business while still working to prevent people with disabilities and those who are aging from becoming infected by COVID-19.

TennCare is Tennessee’s state Medicaid program and administers services to over 1.4 million people. As part of a statewide workforce initiative, TennCare sought a method to regularly collect, analyze, and use provider, 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. This is the fourth year of 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 the summary of data from 131 provider organizations that completed the survey regarding their workforce in those programs.

Year Four Methodology

Year Four Survey Development & Administration

The year four survey (using calendar year 2021 data) maintained the same format as that of year three with four exceptions. First, aging and disabilities only organizations were added to the sample; therefore, the wording throughout the survey was changed to reflect Caregivers/DSPs. Second, two additional CHOICES service types (adult day care and respite) were added to the existing 15 service types. Third, a question was added near the beginning of the survey for organizations to select which broad service types (ECF CHOICES, DIDD Waiver, Vocational Rehabilitation, and CHOICES (Non-ECF CHOICES) were provided. Last, one item was modified. It originally asked the number of DSPs providing services in each of 15 service types. It was changed to ask Caregivers/DSPs to be listed in the one of 17 service types where they spend the majority of their time providing services. These changes were sent to TennCare and the Managed Care Organization (MCO) leads from Amerigroup, BlueCare TN, and UnitedHealthcare for their approval before they were incorporated into the survey. The finalized survey was converted into an online Qualtrics survey. An internal pilot test was conducted to assure the new and modified items functioned as intended. Since the main content and format of this survey was the same as year three, there was no need for an external pilot test. The year four survey launched on June 1, 2022. A webinar was delivered on June 8, 2022, for all organizations invited to complete the year four survey. The purpose of the webinar was to provide an introduction to the survey, clarify issues that were more difficult for participants in previous years, and to answer questions. It 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 27, 2022. During the data cleaning phase, follow-up was done with all organizations who provided data that were inconsistent and/or had other issues that needed clarification. Clean-up and analyses were conducted from July 28, 2022 to August 12, 2022.

Recruitment, Sample, and Response Rate

The Amerigroup, BlueCare TN, and UnitedHealthcare MCOs provided a list of organizations that employ Caregivers/DSPs and participate in ECF CHOICES and CHOICES. The list included the original 114 organizations providing ECF CHOICES located within the three regions of Tennessee. An additional 266 organizations providing CHOICES were added for a sample frame of 380 organizations. Of these, 18 (5%) opted out and 11 (3%) did not meet qualification criteria for year four. This left a sample of 351 organizations who were sent an invitation letter by email and links to participate in the year four survey. MCOs verified each organization’s address, primary contact person, and that person’s contact information. ICI drafted an invitation letter to the organizations in the sample, and MCOs reviewed and distributed the letter. The letter introduced the survey to the organizations by communicating its purpose, how the data would be used, how it would be helpful to them, and encouraged participation.

Of the 351 participants in year four, 131 (37%) submitted a year four survey, 59 (17%) started the survey but did not complete it, and 161 (46%) did not respond at all. Of the 131 submitted surveys, 29 (22%) participated in year one, 39 (30%) participated in year two, 42 (32%) participated in year three, and 80 (61%) were new participants. Of the 131 organizations, 25 (19%) had data for all four years.

The 131 organizations who submitted a survey were included in the year four analysis. 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 131 organizations, 41 (31%) provided their highest percentage of service in the East counties, 44 (34%) provided their highest percentage of service in the Middle counties, and 46 (35%) provided their highest percentage of service in the West counties. There were 2 organizations that provided equal amounts of services in multiple regions, meaning there was no highest region, and 1 organization that left these items blank. In those instances, their region was assigned by where their administrative/corporate/central office was located.

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. 47 organizations completed the year one survey reporting on calendar year 2018.

Year Four Results

While this is the fourth year of this project, this survey marks the start of a new sample, now including Caregivers from the aging and disabilities sectors. This means that the results from year four are not comparable to years one, two and three which focused solely on the sector of workforce providing services to individuals with intellectual and developmental disabilities (IDD). It also means that caution needs to be taken when examining trends over time as they apply only to DSPs who have been in the study all four years.

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 for analysis. 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 2021. It is important to note that while 131 organizations participated in the survey, not all organizations answered all questions.

Organization Background

For the purposed of the project and 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 West: 33%
• Tennessee Middle: 34%
• Tennessee East: 33%

Figure 1 indicates the percent of services that 130 organizations provided in the East, Middle, and West regions of Tennessee. In the state, 33% of organizations provided services in the East region, 34% provided services in the Middle region, and 33% provided services in the West region.

When looking at administrative office headquarters, 29% (38 organizations) had their administrative office in the East, 38% (50 organizations) were located in the Middle, and 33% (43 organizations) were located in the West. The majority of organizations provided services in one region (82%), though 8% provided services in two regions and 10% provided services in three regions. Of the 130 organizations who provided information on the regions they served, 42% provided services in the East region, 45% provided services in the Middle region, and 41% provided services in the West region. The total percentage of services in each region adds up to more than 100% as some organizations work in more than one region.

years in business

• fewer than 1 year: 1%
• 1-5 years: 9%
• 6-10 years: 21%
• more than 10 years: 69%

years delivering services

• fewer than 1 year: 1%
• 1-5 years: 13%
• 6-10 years: 18%
• more than 10 years: 68%

As seen in Figure 2, most organizations statewide (69%) have been in business for 10 or more years, 21% for 6 to 10 years, 9% for 1-5 years, and 1% for less than one year. In comparison, most organizations statewide (68%) have provided services for 10 or more years, 18% for 6 to 10 years, 13% for 1 to 5 years, and 1% for less than 1 year.

• family or individual homes: 60%
• agendy or facility sites: 23%
• job sites: 9%
• other sites: 8%

Figure 3 summarizes the percentage of service sites 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 (60%), followed by agency or facility sites (23%), job sites (9%), and other sites (8%). The other category includes all sites that did not fit into the listed service site categories.

In the East, 26% of organizations provided services in agency or facility sites, 55% provided services in family or individual homes, 15% provided services in job sites, and 4% provided services in other settings. In the Middle, 24% of organizations provided services in agency or facility sites, 56% provided services in family or individual homes, 10% provided services in job sites, and 10% provided services in other settings. In the West, 18% of organizations provided services in agency or facility sites, 69% provided services in family or individual homes, 4% provided services in job sites, and 9% provided services in other settings.

People Served

[text box (list each acronym on a separate line): 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 86 people (range 1 to 800). The average number of people served in the East region was 98 (range 1 to 800) in 41 organizations. The average number of people served in the Middle region was 66 (range 3 to 432) in 42 organizations. The average number of people served in the West region was 95 (range 1 to 650) in 44 organizations.

Organization Staffing

The organizations who responded to the survey supported 10,971 people who are aging, have physical disabilities or those with IDD and employed a total of 15,246 staff. As seen in Figure 4, this included:

• 11,690 Caregivers/DSPs
• 642 frontline supervisors (FLSs)
• 512 managers
• 1,000 administrators, and
• 1,402 other staff.

In the East region, there were 4,016 people served by 41 organizations with supports from 3,883 Caregivers/DSPs and 229 FLSs. There were 218 managers, 497 administrators, and 469 other staff. There were 5,296 total staff in the East. In the Middle region, there were 2,776 people served by 42 organizations with supports from 3,025 Caregivers/DSPs and 193 FLSs. There were 142 managers, 273 administrators, and 464 other staff. There were 4,097 total staff in the Middle. For the West region, there were 4,179 people served by 44 organizations with supports from 4,782 Caregivers/DSPs and 220 FLSs. There were 152 managers, 230 administrators, and 469 other staff. There were 5,853 total staff in the West.

• people served: 10,971
• Caregivers/DSPs: 11,690
• FLSs: 642
• managers: 512
• administrative: 1,000
• other staff: 1,402
• total staff: 15,246

On average across the state, organizations employed 90 Caregivers/DSPs, including on-call, temporary, and relief positions; 5 FLSs; 4 managers; 8 administrators (e.g., administrative, executive director, human resources/payroll); and 11 other employees.

Organizations were asked to report the number of full-time, part-time, and on-call Caregivers/DSPs they employ. Of the 124 reporting organizations, across the state, 55% were full-time Caregivers/DSPs, 42% were part-time, and 3% were on-call/temporary or relief staff. Sixty percent of Caregivers/DSPs worked across more than one service type. Figure 5 shows this Caregiver/DSP staffing pattern in the state.

• on-call/temp: 3%
• part-time: 42%
• full-time: 55%

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

• In the East, 68% were full-time, 29% were part-time, and 3% were on-call/temporary or relief staff. Fifty-eight percent of the Caregivers/DSPs worked across more than one service type.
• In the Middle, 64% were full-time, 33% were part-time, and 3% were on-call/temporary or relief staff. Sixty-two percent of the Caregivers/DSPs worked across more than one service type.
• In the West, 35% were full-time, 62% were part-time, and 3% were on-call/temporary or relief staff. Sixty-one 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 129 organizations who specified the number of hours per week a Caregiver/DSP needs to work to be considered full-time, 3% required Caregivers/DSPs to work 29 hours per week or less, 36% at least 30-34 hours, 23% at least 35-39 hours, and 34% at least 40 hours per week. Five organizations selected the other category and indicated that full-time staff are designated based on the ACA definition, and others reported they do not have or offer full-time packages for employees.

For the 40 organizations in the East region who specified the number of hours per week a Caregiver/DSP needs to work to be considered full-time, 3% required Caregivers/DSPs to work 29 hours per week or less, 50% at least 30-34 hours, 28% at least 35-39 hours, and 15% at least 40 hours per week, and 4% selected the other category. For the 44 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, 30% at least 30-34 hours, 27% at least 35-39 hours, 36% at least 40 hours per week, and 5% selected the other category. For the 45 organizations in the West region who specified the number of hours per week a Caregiver/DSP needs to work to be considered full-time, 5% required 29 hours per week or less, 31% at least 30-34 hours, 13% at least 35-39 hours, 49% at least 40 hours per week, and 2% 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, Employment Community First CHOICES (ECF), and 1915(c) Waiver Programs—to increase access to HCBS, strengthen the HCBS workforce, and build provider capacity to meet the needs of individuals receiving HCBS in these programs (Moss, 2022).

Organizations reported on the wages paid to Caregivers/DSPs, including starting wages, average wages, and highest wages paid on December 31, 2021. 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 $12.05, the overall average wage for all Caregivers/DSPs was $12.60, and the average highest wage for all Caregivers/DSPs was $14.47.

Organizations were asked to report whether Caregivers/DSPs who work in different service types are paid the same wage for each service. Overall, 17% of organizations pay Caregivers/DSPs different wages for each service type. In the East region 15% of organizations pay Caregivers/DSPs different wages for each service type. In the Middle region was higher at 20% of organizations paying Caregivers/DSPs different wages for each service type. In the West region 16% pay Caregivers/DSPs different wages for each service type.

• average starting hourly wage: $12.05
• average hourly wage: $12.60
• average highest hourly wage: $14.47

Starting Caregiver/Direct Support Professional Wages

The average starting wage for part-time Caregivers/DSPs was $12.11 (range $9.00 to $16.90). The average starting wage for full-time Caregivers/DSPs was $12.16 (range $9.50 to $19.00). The average starting wage for Caregivers/DSPs overall was $12.05 (range $9.00 to $16.90). These wages are depicted in Figure 7.

• overall State: $12.05
• overall East: $11.98
• overall Middle: $12.49
• overall: West: $11.69
• full-time State: $12.16
• full-time East: $11.74
• full-time Middle: $12.58
• full-time: West: $12.13
• part-time State: $12.11
• part-time East: $11.74
• part-time Middle: $12.47
• part-time: West: $12.06

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 $11.74 (range $9.00 to $13.77). The average starting wage for full-time Caregivers/DSPs was $11.74 (range $10.00 to $14.00). The average starting wage for all Caregivers/DSPs was $11.98 (range $9.00 to $14.00).
• In the Middle, the average starting wage for part-time Caregivers/DSPs was $12.47 (range $10.00 to $16.90). The average starting wage for full-time Caregivers/DSPs was $12.58 (range $10.00 to $19.00). The average starting wage for all Caregivers/DSPs was $12.49 (range $10.00 to $16.90).
• In the West, the average starting wage for part-time Caregivers/DSPs was $12.06 (range $10.00 to $15.00). The average starting wage for full-time Caregivers/DSPs was $12.13 (range $9.50 to $15.00). The average starting wage for all Caregivers/DSPs was $11.69 (range $9.00 to $15.00).

Average Caregiver/Direct Support Professional Wages

• overall State: $12.60
• overall East: $12.66
• overall Middle: $13.08
• overall: West: $12.09
• full-time State: $12.72
• full-time East: $12.55
• full-time Middle: $13.34
• full-time: West: $12.21
• part-time State: $12.60
• part-time East: $12.40
• part-time Middle: $13.28
• part-time: West: $12.07

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 $12.60 (range $9.50 to $21.00). The average full-time Caregiver/DSP wage was $12.72 (range $9.50 to $19.35). The average overall Caregiver/DSP wage was $12.60 (range $9.50 to $20.00). Figure 8 indicates the part-time, full-time, and overall wages. As with the starting wages, there is little variation in Caregiver/DSP average hourly wages by region.

• In the East, the average wage for part-time Caregivers/DSPs was $12.40 (range $9.50 to $16.00). The average wage for full-time Caregivers/DSPs was $12.55 (range $10.93 to $16.00). The average wage for all Caregivers/DSPs was $12.66 (range $9.50 to $16.00).
• In the Middle, the average wage for part-time Caregivers/DSPs was $13.28 (range $10.50 to $21.00). The average wage for full-time Caregivers/DSPs was $13.34 (range $10.50 to $19.35). The average wage for all Caregivers/DSPs was $13.08 (range $10.50 to $18.00).
• In the West, the average wage for part-time Caregivers/DSPs was $12.07 (range $9.50 to $15.00). The average wage for full-time Caregivers/DSPs was $12.21 (range $9.50 to $15.00). The average wage for all Caregivers/DSPs was $12.09 (range $9.50 to $20.00).

Highest Caregiver/Direct Support Professional Wages

• overall State: $14.47
• overall East: $14.95
• overall Middle: $15.40
• overall: West: $13.07
• full-time State: $14.51
• full-time East: $14.57
• full-time Middle: $15.23
• full-time: West: $13.64
• part-time State: $13.74
• part-time East: $13.97
• part-time Middle: $14.27
• part-time: West: $12.97

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 $13.74 (range $10.50 to $34.00). The average highest wage for full-time Caregivers/DSPs was $14.51 (range $9.50 to $34.00). The average highest wage for all Caregivers/DSPs was $14.47 (range $9.50 to $34.00). 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 $13.97 (range $10.50 to $34.00). The average highest wage for full-time Caregivers/DSPs was $14.57 (range $11.00 to $34.00). The average highest wage for all Caregivers/DSPs was $14.95 (range $10.50 to $34.00).
• In the Middle, the average highest wage for part-time Caregivers/DSPs was $14.27 (range $12.02 to $25.00). The average highest wage for full-time Caregivers/DSPs was $15.23 (range $12.50 to $32.00). The average highest wage for all Caregivers/DSPs was $15.40 (range $11.00 to $32.00).
• In the West, the average highest wage for part-time Caregivers/DSPs was $12.97 (range $11.00 to $20.00). The average highest wage for full-time Caregivers/DSPs was $13.64 (range $9.50 to $20.25). The average highest wage for all Caregivers/DSPs was $13.07 (range $9.50 to $20.25).

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 2021.

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. Regional data for the amount of wage increases were reported by a small number of organizations and should be interpreted with caution. Monetary amounts for wage increases or bonuses were also reported by a small number of organizations, so interpret with caution as they may not be representative of all organizations.

As seen in Table 1, 62% of organizations across the state provided an hourly wage increase for Caregivers/DSPs once training was completed. In the East, 59% of organizations gave an hourly wage increase for Caregivers/DSPs once training was completed. In the Middle, 58% of organizations reported an hourly wage increase for Caregivers/DSPs once training was completed. In the West, 67% of organizations reported an hourly wage increase for Caregivers/DSPs once training was completed. The average increase of hourly wages in the state after training was completed was $1.55. By region, the average hourly wage increase after training was completed was $1.61 in the East, $1.77 in the Middle, and $1.31 in the West.

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 2021. Statewide, 46% of organizations provided an hourly wage increase to Caregivers/DSPs for longevity. In the East, 46% of organizations gave hourly wage increases for longevity to Caregivers/DSPs. In the Middle, 36% of organizations gave an hourly wage increase to Caregivers/DSPs for longevity. In the West, 54% of organizations gave hourly wage increases for longevity to Caregivers/DSPs (see Table 1). The average amount of wage increase for longevity across the state was $0.94 for all Caregivers/DSPs. By region, the average amount of wage increase for longevity was $0.67 in the East, $1.13 in the Middle, and $1.04 in the West.

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 Caregivers/DSP is hired. Of the organizations who gave hourly wage increases for longevity, 25% gave an hourly wage increase for longevity at 1-3 months, 23% gave one at 4-6 months, 4% gave one at 7-9 months, and 54% gave an hourly wage increase for longevity at 10-12 months for all Caregivers/DSPs. There were insufficient responses to report out 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 2021. As seen in Table 1, 58% of the organizations provided wage increases for reasons other than longevity across the state. The percent of organizations who gave hourly wage increases for reasons other than longevity varied across the regions of Tennessee. In the East, 73% of organizations gave hourly wage increases for reasons other than longevity to Caregivers/DSPs. In the Middle, 49% of organizations gave hourly wage increases for reasons other than longevity to Caregivers/DSPs. In the West, 52% of organizations gave hourly wage increases to Caregivers/DSPs for reasons other than longevity. The average amount of this hourly wage increase for reasons other than longevity was $1.22 across the state, $1.07 in the East, $1.39 in the Middle, and $1.28 in the West.

Caregiver/Direct Support Professaional Bonuses

Questions about monetary referral, hiring, years of service, and performance recognition bonuses were included in the survey. Regional data for the amount of bonus and number of Caregivers/DSPs who received a bonus were reported by a small number of organizations, so caution is required when interpreting the results about Caregivers/DSP bonuses.

Referral bonus

Organizations may give referral bonuses to current employees to encourage inside recruitment. The employees share information about the work to 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, 52% of organizations gave a referral bonus to Caregivers/DSPs across the state. By region, 63% of organizations provided referral bonuses in the East, 51% provided referral bonuses in the Middle, and 43% of organizations provided referral bonuses in the West. The average employee referral bonus in the state was $224. By region, the average referral bonus was $184 in the East, $275 in the Middle, and $220 in the West. For organizations who provided referral bonuses, the average number of Caregivers/DSPs who received referral bonuses was 12 across the state. By region, the average number of Caregivers/DSPs in an organization who received a referral bonus was seven in the East, 10 in the Middle, and 23 in the West.

Hiring bonus

A hiring bonus is 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, 24% of organizations provided a hiring bonus to newly hired Caregivers/DSPs. By region, 20% of organizations provided hiring bonuses in the East, 33% of organizations provided hiring bonuses in the Middle, and 21% of organizations provided hiring bonuses in the West (see Table 3). The average hiring bonus in the state was $405. By region, the average hiring bonus was $625 in the East, $346 in the Middle, and $300 in the West. For organizations who provided a hiring bonus, the average number of Caregivers/DSPs who received a hiring bonus was 36 across the state. By region, the average number of Caregivers/DSPs in an organization who received a hiring bonus was 31 in the East, 13 in the Middle, and 80 in the West.

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, 28% of organizations gave a bonus to Caregivers/DSPs for years of service across the state. By region, 29% of organizations provided years of service bonuses in the East, 27% of organizations provided years of service bonuses in the Middle, and 28% of organizations provided years of service bonuses in the West. The average employee bonus for years of service in the state was $249. By region, the average bonus for years of service was $273 in the East, $388 in the Middle, and $115 in the West. For organizations who provided a bonus for years of service, the average number of Caregivers/DSPs who received a bonus for years of service was 54 across the state. By region, the average number of Caregivers/DSPs in an organization who received a bonus for years of service was 94 in the East, 28 in the Middle, and 44 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, 33% of organizations gave a performance recognition bonus to Caregivers/DSPs. By region, 34% of organizations provided performance recognition bonuses in the East, 33% of organizations provided performance recognition bonuses in the Middle, and 31% of organizations provided recognition bonuses in the West (see Table 3). The average employee performance recognition bonus in the state was $194. By region, the average performance recognition bonus was $204 in the East, $292 in the Middle, and $68 in the West. For organizations who provided performance recognition bonuses, the average number of Caregivers/DSPs per organization who received a performance recognition bonus was 20. By region, the average number of Caregivers/DSPs in an organization who received a performance recognition bonus was 18 in the East, 17 in the Middle, and 26 in the West.

Other bonuses

Across the state, 29% of organizations provided bonuses to Caregivers/DSPs for reasons other than employee referral, hiring, years of service, or performance recognition bonuses. By region, 27% of organizations provided a bonus for other reasons in the East, 42% of organizations provided a bonus for other reasons in the Middle, and 19% 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:

• Extra funds
• Attendance
• Caregiver appreciation week
• Christmas/winter bonus
• Covering additional shifts
• EW compliance
• End of year bonus
• Holiday
• Retention bonus
• Shift differentials

The average bonus for reasons other than employee referral, hiring, years of service, or performance recognition bonuses in the state was $361. By region, the average bonus for other reasons was $107 in the East, $301 in the Middle, and $845 in the West. For organizations who provided a bonus for other reasons, the average number of Caregivers/DSPs who received a bonus for other reasons was 86 across the state. By region, the average number of Caregivers/DSPs in an organization who received a bonus for other reasons was 133 in the East, 46 in the Middle, and 96 in the West.

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; Test et al., 2003). 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 38 (range 14 to 85) 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 45) hours per week and full-time Caregivers/DSPs worked an average of 41 (range 15 to 80) hours per week.

• In the East region across all organizations, Caregivers/DSPs worked an average of 41 (range 21 to 85) hours per week. For organizations who could differentiate between part-time and full-time employees, part-time Caregivers/DSPs worked an average of 24 (range 10 to 34) hours per week and full-time Caregivers/DSPs worked an average of 41 (range 28 to 50) hours per week.
• In the Middle region across all organizations, Caregivers/DSPs worked an average of 41 (range 15 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 7 to 40) hours per week and full-time Caregivers/DSPs worked an average of 44 (range 15 to 80) hours per week.
• In the West region across all organizations, Caregivers/DSPs worked an average of 32 (range 14 to 69) 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 45) hours per week and full-time Caregivers/DSPs worked an average of 38 (range 25 to 48) hours per week.

Caregiver/Direct Support Professional Overtime Hours

• 2,881,536 overtime hours in 2021

Organizations reported overtime hours paid to Caregivers/DSPs in 2021. Figure 10 indicates the overall number of overtime hours paid to Caregivers/DSPs in 2021. Across the state, the average number of overtime hours that organizations paid out to Caregivers/DSPs in 2021 was 26,930 (range 0 to 488,280). The total number of overtime hours paid out in 2021 from 107 organizations was 2,881,536. In the East, the average number of overtime hours paid out was 34,662 (range 0 to 488,280) with a total of 1,282,498 overtime hours paid to Caregivers/DSPs. In the Middle, the average number of overtime hours paid out was 13,367 (range 0 to 58,031) with a total of 481,226 overtime hours paid to Caregivers/DSPs. In the West, the average number of overtime hours paid out was 32,877 (range 0 to 427,191) with a total of 1,117,812 overtime hours paid to Caregivers/DSPs.

Caregiver/Direct Support Professional Cost of Overtime

Total cost of Caregiver/DSP overtime in 2021

• $18,471,076 cost of overtime in 2021

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 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 2021, 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 2021. There is the regular hourly wage. When divided by 2, this gives the wage for the extra time - the extra one-half. 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 2021 was $179,331 (range $0 to $3,832,998) for participating organizations. The total cost of Caregiver/DSP overtime in 2021 from 103 organizations was $18,471,076.

• In the East region, the average cost of Caregiver/DSP overtime in 2021 was $241,060 (range $0 to $3,832,998). The total cost of Caregiver/DSP overtime in 2021 from 36 organizations was $8,678,158.
• In the Middle region, the average cost of Caregiver/DSP overtime in 2021 was $80,771 (range $0 to $354,569). The total cost of Caregiver/DSP overtime in 2021 from 34 organizations was $2,746,223.
• In the West region, the average cost of Caregiver/DSP overtime in 2021 was $213,536 (range $0 to $2,998,881). The total cost of Caregiver/DSP overtime in 2021 from 33 organizations was $7,046,695.

The cost of overtime for the state in 2021 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 et al., 2021a). Organizations also report that they have difficulties recruiting people to fill open positions due to terminations (voluntary and involuntary) and growth in need for services. For these reasons, 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 21%. The average vacancy rate for part-time positions was 26%, and the average vacancy rate for full-time positions was 21%.

• overall: 21%
• part-time: 26%
• full-time: 21%

In the East, the average vacancy rate among full-time Caregivers/DSPs was 23%. The average part-time Caregiver/DSP vacancy rate was 24%. The average vacancy rate among all Caregiver/DSP positions was 22%. In the Middle, the average vacancy rate among full-time Caregivers/DSPs was 17%. The average part-time Caregiver/DSP vacancy rate was 31%. The average vacancy rate among all Caregiver/DSP positions was 21%. In the West, the average vacancy rate among full-time Caregiver/DSP positions was 25%. The average vacancy rate among part-time Caregiver/DSP position in the West region was 22%. The average vacancy rate among all Caregiver/DSP positions was 21%.

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 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 2021 was 45%. Turnover among part-time Caregivers/DSPs was 57%. The overall Caregiver/DSP annual turnover rate was 56%.

• In the East, the average turnover rate among full-time Caregivers/DSPs was 55%. Among part-time Caregivers/DSPs, the average turnover rate was 49%. The average turnover rate among all Caregivers/DSPs in the region was 60%.
• In the Middle, the average turnover rate among full-time Caregivers/DSPs was 39%. Among part-time Caregivers/DSPs, the average turnover rate was 54%. The average turnover rate for all Caregivers/DSPs in the Middle region was 50%.
• In the West, the average turnover rate among full-time Caregivers/DSPs was 44%. The average turnover rate among part-time Caregivers/DSPs was 66%. The average turnover rate among all Caregivers/DSPs in the West region was 61%.

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

• overall annual turnover: 56%
• turnover within 0-6 months: 57%
• turnover within 6-12 months: 28%

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 are unmet and 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 in meeting qualification. Turnover is extremely costly for organizations, estimated between $3,278-4,872 per DSP who leaves (Larson et al., 2016), although these data were collected in the early 2000's and have not been adjusted for inflation. It is also detrimental for people who receive DSP supports when there is little time to develop a professional relationship with a DSP before a new one is hired (Friedman, 2018). Every Caregiver/DSP who leaves the organization requires an existing employee to backfill the vacated shifts while a new Caregiver/DSP is hired and trained. Data were gathered to show the percent 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 57% across all Caregivers/DSPs, 70% for part-time Caregivers/DSPs, and 44% 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, 70% for part-time Caregivers/DSPs, and 52% for full-time Caregivers/DSPs. In the Middle region, the average Caregiver/DSP separation rate within 0-6 months of hire was 57% across all Caregivers/DSPs, 75% for part-time Caregivers/DSPs, and 32% for full-time Caregivers/DSPs. In the West region, the average Caregiver/DSP separation rate within 0-6 months of hire was 58% across all Caregivers/DSPs, 64% for part-time Caregivers/DSPs, and 48% 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, 25% for part-time Caregivers/DSPs, and 37% for full-time Caregivers/DSPs. In the East region, the average Caregiver/DSP separation rate within 6 to 12 months of hire was 20% across all Caregivers/DSPs, 11% for part-time Caregivers/DSPs, and 25% for full-time Caregivers/DSPs. In the Middle region, the average Caregiver/DSP separation rate within 6 to 12 months of hire was 35% across all Caregivers/DSPs, 33% for part-time Caregivers/DSPs, and 41% for full-time Caregivers/DSPs. In the West region, the average Caregiver/DSP separation rate within 6 to 12 months of hire was 27% across all Caregivers/DSPs, 26% 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 (87%) 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 providers 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” (52%) was the third most commonly given reason. “Termination or being fired” (26%), “not a good fit for the type of work” (21%), “advanced to a new position within the company in a different service” (7%), “could not get along with co-workers” (3%), and “training/support was inadequate” (2%) were selected by some organizations. “Having too little or poor quality time with their supervisor” (0%), and “not recognized for the work they did” (0%) were not selected by any organizations. There were some regional differences in percentages of organizations that selected the reasons, but the largest percentage of providers selected the same top four reasons in each of the three regions and the state.

Nearly one-fifth (19%) 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
• Failed to complete orientation
• Going back to school
• Job circumstances (e.g., extra hours, shifts, etc.)
• Medical reasons
• Personal reasons, and
• Retired.

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 interpret with caution.

As seen in Table 6, 48% of the organizations offered paid time off (PTO) to some or all of their Caregivers/DSPs. Of the 42 organizations that reported the money spent on PTO, the average amount spent was $74,555. Eighteen percent of organizations offered paid sick leave to some or all of their Caregivers/DSPs. Of the seven organizations that reported the money spent on paid sick leave, the average amount was $20,045. Twenty-three percent of organizations offered paid vacation to some or all of their Caregivers/DSPs. Of the 11 organizations that reported the money spent on paid vacation, the average amount was $31,291.

Health Insurance

Across the state, 56% of the 126 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 30 (range 0 to 40 hours). On average, 30% (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 $412 per Caregiver/DSP for health insurance premium contributions each month for single coverage, $615 for single plus 1 coverage, and $783 for family coverage. The average employee’s contribution for monthly health insurance premium contribution was $156 for single coverage, $537 for single plus 1 coverage, and $878 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 starting salary: $34,180
• average annual salary: $36,611
• highest average salary: $43,629

Figure 14 shows the average FLS starting, average, and highest salaries. The average starting salary for FLSs across the state was $34,180 (range $5,000 to $64,402). By region, the average starting salary for FLSs was $33,564 (range $5,000 to $62,402) in the East, $35,489 (range $18,000 to $60,000) in the Middle, and $33,427 (range $24,000 to $55,000) in the West.

The overall average salary for FLSs across the state was $36,611 (range $5,000 to $66,563). By region, the average salary for FLSs was $36,559 (range $5,000 to $66,563) in the East, $37,544 (range $19,000 to $63,000) in the Middle, and $35,617 (range $25,000 to $55,000) in the West.

The average highest salary for FLSs across the state was $43,629 (range $5,000 to $125,000). By region, the average highest salary for FLSs was $42,192 (range $5,000 to $82,000) in the East, $43,702 (range $21,225 to $90,000) in the Middle, and $45,030 (range $27,000 to $125,000) 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 annual turnover: 41%
• turnover within 0-6 months: 28%
• turnover within 6-12 months: 51%

The average FLS turnover throughout the state was 41%. By region, the average turnover of FLSs was 45% in the East, 33% in the Middle, and 46% 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 quite 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 percent 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 28%. By region, the average FLS separation rate within 0 to 6 months of hire was 33% in the East, 22% in the Middle, and 27% 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 51%. By region, the average FLS separation rate within 6 to 12 months of hire was 41% in the East, 58% in the Middle, and 54% 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 at the site.

• overall: 15%

As seen in Figure 16, the average FLS vacancy rate was 15% across the state. By region, the average FLS vacancy rate was 16% in the East, 9% in the Middle, and 22% in the West.

Service Areas

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

• CHOICES (Non-ECF CHOICES): 79%
• ECF CHOICES: 54%
• DD Waiver: 44%
• Vocational Rehabiltation: 15%

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 131 organizations, 79% provided CHOICES (Non-ECF CHOICES), 54% ECF CHOICES, 44% DIDD Waiver Service, and 15% 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 127 organizations who answered service types, all provided at least one service type. Forty percent provided two or three service types, 18% provided four or five service types, and 20% provided between six and 10 service types. Fifteen percent of organizations provided between 11 and 16 service types. Two percent of organizations provided all 17 service types.

ECF CHOICES Qualified Job Developer

As seen in Table 8, 43% of organizations providing ECF CHOICES services provided ECF Choices Employment Services Requiring a Qualified Job Developer. For the 14 organizations who answered, 3% (range 0% to 29%) 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 $13.28 and the average wage overall was $14.17. On average, there were 5,878 (range 0 to 58,686) overtime hours paid to Caregiver/DSPs in 2021. There was a total of 58,777 overtime hours paid to Caregiver/DSPs in 2021. The average annual cost for Caregiver/DSP overtime was $35,839 (range $0 to $357,691). The total annual cost for Caregiver/DSP overtime was $358,387 in 2021.

ECF CHOICES Qualified Job Coach

Forty-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 11%) 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 $12.84 and the average wage overall was $13.70. On average, there were 6,722 (range 0 to 58,686) overtime hours paid to Caregiver/DSPs in 2021. There was a total of 60,496 overtime hours paid to Caregiver/DSPs in 2021. The average annual cost for Caregiver/DSP overtime was $41,101 (range $0 to $357,691). The total annual cost for Caregiver/DSP overtime was $369,905 in 2021 (see Table 9).

ECF CHOICES Community Integration Support Services/Independent Living Skills Training

As seen in Table 10, 68% of organizations providing ECF CHOICES services provided ECF Choices Community Integration Support Services/Independent Living Skills Training. For the 22 organizations who answered, 11% (range 0% to 100%) 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 $12.42 and the average wage overall was $13.19. On average, there were 36 (range 0 to 236) overtime hours paid to Caregiver/DSPs in 2021. There was a total of 540 overtime hours paid to Caregiver/DSPs in 2021. The average annual cost for Caregiver/DSP overtime was $256 (range $0 to $1,709). The total annual cost for Caregiver/DSP overtime was $3,583 in 2021.

ECF CHOICES Community Living Supports (CLS)

Seventy-one percent of organizations providing ECF CHOICES services provided ECF Choices Community Living Supports. For the 24 organizations who answered, 16% (range 0% to 71%) 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 $12.31 and the average wage overall was $13.16. On average, there were 4,688 (range 0 to 49,600) overtime hours paid to Caregiver/DSPs in 2021. There was a total of 75,009 overtime hours paid to Caregiver/DSPs in 2021. The average annual cost for Caregiver/DSP overtime was $32,740 (range $0 to $386,880). The total annual cost for Caregiver/DSP overtime was $458,353 in 2021 (see Table 11).

ECF CHOICES Personal Assistance and/or Supportive Home Care

As seen in Table 12, 70% of organizations providing ECF CHOICES services provided ECF Choices Personal Assistance and/or Supportive Home Care. For the 23 organizations who answered, 20% (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 $11.98 and the average wage overall was $12.60. On average, there were 1,086 (range 0 to 20,731) overtime hours paid to Caregiver/DSPs in 2021. There was a total of 23,902 overtime hours paid to Caregiver/DSPs in 2021. The average annual cost for Caregiver/DSP overtime was $487 (range $0 to $9,295). The total annual cost for Caregiver/DSP overtime was $9,734 in 2021.

DIDD Waiver 1915c Employment Supports

Seventy-nine percent of organizations providing DIDD Waiver Services provided 1915c Employment Supports. For the 22 organizations who answered, 5% (range 0% to 14%) 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 $12.10 and the average wage overall was $12.92. On average, there were 5,247 (range 0 to 58,686) overtime hours paid to Caregiver/DSPs in 2021. There was a total of 62,962 overtime hours paid to Caregiver/DSPs in 2021. The average annual cost for Caregiver/DSP overtime was $32,528 (range $0 to $357,691). The total annual cost for Caregiver/DSP overtime was $390,334 in 2021 (see Table 13).

DIDD Waiver 1915c Residential/Supported Living Services

As seen in Table 14, 89% of organizations providing DIDD Wavier Services provided 1915c Residential/Supportive Living Services. For the 31 organizations who answered, 60% (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 $12.14 and the average wage overall was $12.83. On average, there were 13,059 (range 0 to 90,316) overtime hours paid to Caregiver/DSPs in 2021. There was a total of 235,067 overtime hours paid to Caregiver/DSPs in 2021. The average annual cost for Caregiver/DSP overtime was $97,448 (range $0 to $745,107). The total annual cost for Caregiver/DSP overtime was $1,364,272 in 2021.

DIDD Waiver 1915c Personal Assistance Services

Seventy-seven percent of organizations providing DIDD Waiver Services provided 1915c Personal Assistance Services. For the 24 organizations who answered, 8% (range 0% to 77%) 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 $12.28 and the average wage overall was $12.91. On average, there were 134 (range 0 to 1,462) overtime hours paid to Caregiver/DSPs in 2021. There was a total of 1,873 overtime hours paid to Caregiver/DSPs in 2021. The average annual cost for Caregiver/DSP overtime was $199 (range $0 to $1,238). The total annual cost for Caregiver/DSP overtime was $2,588 in 2021 (see Table 15).

DIDD Waiver 1915c Community Based Services

As seen in Table 16, 88% of organizations providing DIDD Wavier Services provided 1915c Community Based Services. For the 23 organizations who answered, 11% (range 0% to 34%) 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 $12.19 and the average wage overall was $12.89. On average, there were 743 (range 0 to 7,048) overtime hours paid to Caregiver/DSPs in 2021. There was a total of 11,882 overtime hours paid to Caregiver/DSPs in 2021. The average annual cost for Caregiver/DSP overtime was $3,966 (range $0 to $43,521). The total annual cost for Caregiver/DSP overtime was $59,484 in 2021.

DIDD Waiver 1915c Facility Based Services

Forty-five percent of organizations providing DIDD Waiver Services provided 1915c Facility Based Services. For the 13 organizations who answered, 5% (range 0% to 34%) 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 $12.20 and the average wage overall was $12.97. On average, there were 11,429 (range 0 to 91,157) overtime hours paid to Caregiver/DSPs in 2021. There was a total of 91,435 overtime hours paid to Caregiver/DSPs in 2021. The average annual cost for Caregiver/DSP overtime was $241 (range $0 to $1,685). The total annual cost for Caregiver/DSP overtime was $1,685 in 2021 (see Table 17).

Vocational Rehabilitation: Qualified Employment Specialist

As seen in Table 18, 95% of organizations providing Vocational Rehabilitation provided Employment Services Requiring a VR-Qualified Employment Specialist. For the six organizations who answered, 13% (range 0% to 67%) 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 $13.54 and the average wage overall was $13.74. There were no overtime hours paid to Caregiver/DSPs in 2021. The average annual cost for Caregiver/DSP overtime was $124 (range $0 to $741). The total annual cost for Caregiver/DSP overtime was $0 in 2021.

Vocational Rehabilitation Qualified Job Coach

Ninety percent of organizations providing Vocational Rehabilitation provided Employment Services Requiring a VR-Qualified Job Coach. For the nine organizations who answered, 5% (range 0% to 33%) 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 $12.38 and the average wage overall was $12.95. On average, there were 124 (range 0 to 741) overtime hours paid to Caregiver/DSPs in 2021. There was a total of 741 overtime hours paid to Caregiver/DSPs in 2021. The total annual cost for Caregiver/DSP overtime was $0 in 2021 (see Table 17).

CHOICES (Non-ECF CHOICES): Personal Care Services

As seen in Table 20, 79% of organizations providing CHOICES (Non-ECF CHOICES) provided Personal Care. For the 44 organizations who answered, 55% (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 $11.61 and the average wage overall was $12.09. On average, there were 1,608 (range 0 to 34,404) overtime hours paid to Caregiver/DSPs in 2021. There was a total of 70,759 overtime hours paid to Caregiver/DSPs in 2021. The average annual cost for Caregiver/DSP overtime was $9,675 (range $0 to $206,424). The total annual cost for Caregiver/DSP overtime was $416,036 in 2021.

CHOICES (Non-ECF CHOICES): Attendant Care Services

Seventy-three percent of organizations providing CHOICES (Non-ECF CHOICES) provided Attendant Care. For the 37 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 $11.54 and the average wage overall was $12.13. On average, there were 1,640 (range 0 to 34,000) overtime hours paid to Caregiver/DSPs in 2021. There was a total of 65,612 overtime hours paid to Caregiver/DSPs in 2021. The average annual cost for Caregiver/DSP overtime was $9,954 (range $0 to $204,000). The total annual cost for Caregiver/DSP overtime was $378,260 in 2021 (see Table 21).

CHOICES (Non-ECF CHOICES): Community Living Supports

As seen in Table 22, 38% of organizations providing CHOICES (Non-ECF CHOICES) provided Community Living Supports. For the 14 organizations who answered, 21% (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 $12.19 and the average wage overall was $12.68. On average, there were 792 (range 0 to 5,000) overtime hours paid to Caregiver/DSPs in 2021. There was a total of 8,717 overtime hours paid to Caregiver/DSPs in 2021. The average annual cost for Caregiver/DSP overtime was $4,779 (range $0 to $28,750). The total annual cost for Caregiver/DSP overtime was $52,567 in 2021.

CHOICES (Non-ECF CHOICES): Adult Day Care

Twelve percent of organizations providing CHOICES (Non-ECF CHOICES) provided Adult Day Care. For the 5 organizations who answered, 39% (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 $12.14 and the average wage overall was $12.28. On average, there were 13 (range 0 to 50) overtime hours paid to Caregiver/DSPs in 2021. There was a total of 50 overtime hours paid to Caregiver/DSPs in 2021. The average annual cost for Caregiver/DSP overtime was $78 (range $0 to $313). The total annual cost for Caregiver/DSP overtime was $313 in 2021 (see Table 23).

CHOICES (Non-ECF CHOICES): Respite

As seen in Table 24, 74% of organizations providing CHOICES (Non-ECF CHOICES) provided Respite. For the 33 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 $11.32 and the average wage overall was $11.96. On average, there were 478 (range 0 to 9,494) overtime hours paid to Caregiver/DSPs in 2021. There was a total of 18,631 overtime hours paid to Caregiver/DSPs in 2021. The average annual cost for Caregiver/DSP overtime was $1,334 (range $0 to $17,532). The total annual cost for Caregiver/DSP overtime was $50,674 in 2021.

Revenue & Worker’s Compensation Costs

Statewide, the average of the total annual revenue per organization was $9,154,613 (range $6,123 to $294,427,379). By region, the average total annual revenue was $16,205,671 (range $6,123 to $294,427,379) in the East, $4,630,357 (range $60,000 to $45,000,000) in the Middle, and $6,021,229 (range $20,000 to $41,500,000) 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 87% of total dollars were authorized for services, and 88% of the total dollars for services were actually billed. In the Middle, an average of 86% of total dollars were authorized for services, and 87% of the total dollars for services were actually billed. In the West, an average of 80% of total dollars were authorized for services, and 79% of the total dollars for services were actually billed.

Revenue from ECF CHOICES

Across the state, an average of 58% of overall revenue derived from ECF CHOICES rates was directed toward wages for Caregivers/DSPs. By region, 63% of revenue from ECF CHOICES rates were directed toward Caregiver/DSP wages in the East, 63% in the Middle, and 39% in the West. Statewide, an average of 10% of organizations’ overall revenue derived from ECF CHOICES rates was used for Caregiver/DSP worker’s compensation. By region, 3% of overall revenue from ECF CHOICES rates was used for Caregiver/DSP worker’s compensation in the East, 17% in the Middle, and 8% in the West.

Revenue from CHOICES

Across the state, an average of 62% of overall revenue derived from CHOICES rates was directed toward wages for Caregivers/DSPs. By region, 65% of revenue from CHOICES rates were directed toward Caregiver/DSP wages in the East, 52% in the Middle, and 66% in the West. Statewide, an average of 8% of organizations’ overall revenue derived from CHOICES rates was used for Caregiver/DSP worker’s compensation. By region, 3% of overall revenue from CHOICES rates was used for Caregiver/DSP worker’s compensation in the East, 10% in the Middle, and 12% in the West.

COVID-19 Experiences

The COVID-19 pandemic was declared by the World Health Organization in March of 2020, impacting the delivery of services to people receiving long term services and supports and the Caregivers/DSPs who support them. The threat of the virus resulted in stay-at-home orders, social distancing guidelines, and mask mandates. Since the start of the pandemic, research has demonstrated that aging and having intellectual disability are the strongest risk factors for mortality from COVID-19 (Gleason et al., 2021). It was important to ask organizations about some of their experiences in order to have context of how COVID-19 impacted their operations. This may inform practice and policy decisions to better prepare for future waves of the COVID-19 pandemic or other states of disaster.

Organizations were asked to select all of the experiences their organization had undergone in the delivery of services due to the pandemic during 2021.

As seen in Table 25, organizations in the state selected “staff hours were cut” (23%) as the experience most commonly had due to Covid-19. “Staff were relocated (temporarily or permanently) to another setting” (21%) was the second most common experience. “Staff lived in residence(s) to slow COVID-19 spread”, “facility/organization closed due to government mandate”, and “staff positions were eliminated” were each selected by 13%, and “staff were furloughed or laid off” by 8%.

There were some regional differences in percentages of organizations that selected the experiences. In the East, organizations selected “staff were relocated (temporarily or permanently) to another setting” (28%) as the experience most commonly had due to Covid-19, followed by “facility/organization closed due to government mandate” (20%) and “staff lived in residence(s) to slow COVID-19 spread” (18%). The Middle mirrored the state. Organizations selected “staff hours were cut” (18%), “staff were relocated (temporarily or permanently) to another setting” (18%), and “staff lived in residence(s) to slow COVID-19 spread” (15%) were the top three experiences. In the West, organizations selected “staff hours were cut” (43%) as the experience most commonly had due to Covid-19. “Staff positions were eliminated” (25%) was the second most common experience. And, “staff were relocated (temporarily or permanently) to another setting” (18%) was the third most common experience.

Twenty percent of organizations selected “other” experiences during COVID-19. Organizations had the opportunity to write in the “other” experience, which included the following:

• Loss of staff and clients
• Additional expenses for PPE where no additional funding was provided
• Inconsistency for staff (e.g., cancelled visits, services put on hold)
• Mandatory testing provided weekly as well as vaccinations
• Employees stopped working; hard to find replacements
• Staff quit to apply for free benefits
• Too much overtime

Turnover and Hiring Practices During the COVID-19 Pandemic

When asked about whether they were short-staffed as a result of the COVID-19 pandemic, 91% of organizations said they were more short-staffed than before the COVID-19 pandemic.

91% of organizations said they were more short-staffed than before the COVID-19 pandemic.

With staff shortages and additional stressors caused by staff leaving their positions due to the pandemic, nearly three-quarters of organizations (71%) reported that new staff had been hired during the COVID-19 pandemic. When new staff were hired because of the pandemic, 16% of the organizations said new staff received typical orientation and preservice training, 81% said they received the typical orientation and preservice training as well as safety training related to the pandemic, and 3% said that typical orientation and preservice training were not provided.

Salary Augmentation for Caregivers/Direct Support Professionals

Organizations were asked if Caregivers/DSPs were paid more during the COVID-19 pandemic (e.g., essential worker augmentation or COVID-19 bonus). Fifty-eight percent of organizations paid their Caregivers/DSPs more during the COVID-19 pandemic through salary augmentation, many with FMAP/ARPA supported funding. The amount of the wage increase for Caregivers/DSPs is depicted in Figure 18. Of the 58% who offered a salary augmentation, 29% gave an increase of $0.01 to $1.00 per hour, 21% gave $1.01 to $2.00 per hour, 17% gave $2.01 to $3.00 per hour, 9% gave $3.01 or more per hour, and 24% gave a lump sum bonus.

• $0.01-$1.00 per hour: 29%
• $1.01-$2.00 per hour: 21%
• $2.01-$3.00 per hour: 17%
• $3.01+ per hour: 9%
• lump sum: 24%

For organizations giving this wage increase, 91% gave it to all Caregivers/DSPs, 6% to full-time Caregivers/DSPs only, and 3% to part-time Caregivers/DSPs only. Forty-three of organizations reported that the hourly wage increase from COVID-19 has an end date.

COVID-19 Infections & Deaths

Organizations were asked about COVID-19 infections and deaths among their staff and the people whom they serve. For staff, the average percentage of those infected by Covid-19 across the state was 16% (range 0% to 84%). In each region, the average percentage of Covid-19 infections among staff was 21% (range 0% to 83%) in the East, 14% (range 0% to 38%) in the Middle, and 12% (range 0% to 34%) in the West. The percentage of deaths due to Covid-19 among staff was <1%, on average, for the state and across regions.

For people served the average percentage of those infected by Covid-19 across the state was 16% (range 0% to 100%). In each region, the average percentage of Covid-19 infections was 14% (range 0% to 64%) in the East, 21% (range 0% to 100%) in the Middle, and 13% (range 0% to 75%) in the West. The percentage of deaths due to Covid-19 among people served was 2%, on average, for the state, 1% in the East and Middle regions, and 2% in the West region.

Direct Support Professionals and Frontline Supervisor Trends Over Time

There were 25 organizations with DSPs and FLSs that participated in all four years of the QulLTSS Workforce Initiative Survey. 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 operated over the four years. FLS average scores for turnover, early turnover, vacancy rates, and salaries were examined to see how they operated over three years. The questions about FLS were not asked in the first survey.

Due to the small number of organizations completing all four surveys, trends could not be examined by region or by part- and full-time DSPs and statistical tests could not be conducted. Instead, an inspection of the average scores was done to look at trends. There were several additional issues affecting the interpretation of these results. On face value, we can see whether numbers went up or down over time. However, the interpretation of why they moved is less certain as the trend cannot be attributed to any specific intervention or strategy implemented. One of the assumptions when examining data over time is that the measurement instrument, in this case, the survey, remains consistent across time points. This survey was significantly reduced in length, a few new items were added, and the survey was also substantially reformatted after year one. In the fourth year, the survey sample frame was increased with additional service types included which impacted the wording of every item slightly. This may have changed the interpretation of questions for those who had taken the survey previously. Additionally, there is usually an intervention component where data are tracked to help understand change in the outcomes. These data were not available for all four years. And, lastly, other major unanticipated events influenced the data over the four years including 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 the access to HCBS, strengthening the HCBS workforce and building provider capacity were outlined in the Tennessee HCBS FMAP funding plan submitted and approved by the Centers for Medicare & Medicaid Services (CMS). The pandemic affected organization functioning, specifically staffing and wages with augmentations. These events had an impact on 2020 and 2021 data although the degree of effect is not known.

While we can discuss the below 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 and the sample size for examining trends is small and may not be representative of the Tennessee DSP workforce.

In the sections below that examine trends over time, only DSPs are included, as the Caregiver sample was added in year four and does not have comparison group to previous surveys.

Direct Support Professional Retention Rates

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

Annual DSP turnover tells the percentage of DSPs who left the organization (turned over) in the last year out of all DSP positions. As seen in Figure 19, the average annual turnover was 55% in 2018, 44% in 2019, 41% in 2020, and 46% in 2021.

Early DSP turnover within 0-6 months of hire tells the percentage of DSPs who left their position within the first 6 months of starting the job. For DSPs, the average early turnover within 0-6 months of hire was 51% in 2019 and 46% in 2020 and 2021.

DSP turnover within 6-12 months of hire tells the percentage of DSPs who left their position within 6-12 months of starting the job. For DSPs, the average turnover within 6-12 months of hire was 27% in 2019, 26% in 2020, and 18% in 2021.

DSP vacancy rate tells the percentage of vacant positions out of all of the DSP positions. The average DSP vacancy rate was 13% in 2018, 12% in 2019, and 22% in 2020 and 2021.

turnover

• 2018: 55%
• 2019: 44%
• 2020: 41%
• 2021: 46%

early turnover, 0-6 months

• 2019: 51%
• 2020: 46%
• 2021: 46%

turnover in first year, 6-12 months

• 2019: 27%
• 2020: 26%
• 2021: 18%

vacancy

• 2018: 13%
• 2019: 12%
• 2020: 22%
• 2021: 22%

Note: 18 organizations reported turnover, 21 early turnover (0-6M), 21 turnover between 6-12M, and 18 for vacancy.

Direct Support Professional Hourly Wages

Organizations provided data for DSP starting hourly wages, average hourly wages, and highest hourly wages. As seen in Figure 20, the average DSP starting hourly wage was $9.34 in 2018, $9.83 in 2019, $10.12 in 2020, and $12.13 in 2021. The average DSP hourly wage was $10.22 in 2018, $10.39 in 2019, $10.91 in 2020, and $12.58 in 2021. The average DSP highest hourly wage was $11.45 in 2018, $12.81 in 2019, $12.96 in 2020, and $14.94 in 2021.

starting hourly wage

• 2018: $ 9.34
• 2019: $9.83
• 2020: $10.12
• 2021: $12.13

hourly wage

• 2018: $10.22
• 2019: $10.39
• 2020: $10.91
• 2021: $12.58

highest hourly wage

• 2018: $11.45
• 2019: $12.81
• 2020: $12.96
• 2021: $14.94

Note: 23 organizations reported for starting hourly wage, 13 for hourly wage, and 12 for highest hourly wage.

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.

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 21, the average FLS annual turnover was 19% in 2019, 18% in 2020, and 19% in 2021. The average early turnover within 0-6 months of hire was 42% in 2019, 27% in 2020, and 42% in 2021. The average turnover within 6-12 months of hire was 44% in 2019, 43% in 2020, and 24% in 2021. The average vacancy rate was 8% in 2019, 10% in 2020, and 8% in 2021.

turnover

• 2019: 19%
• 2020: 18%
• 2021: 19%

early turnover, 0-6 months

• 2019: 42%
• 2020: 27%
• 2021: 42%

turnover in first year, 6-12 months

• 2019: 44%
• 2020: 43%
• 2021: 24%

vacancy

• 2019: 8%
• 2020: 10%
• 2021: 8%

Note: 14 organizations reported turnover, 10 reported early turnover 0-6M, 7 reported early turnover 6-12M, and 15 reported vacancy rate.

Frontline Supervisor Salaries

Organizations provided data for FLS starting salary, annual salary, and highest salary. As seen in Figure 22, the average FLS starting salary was $29,438 in 2019, $30,152 in 2020, and $33,391 in 2021. The average FLS annual salary was $35,321 in 2019, $33,669 in 2020, and $35,623 in 2021. The average FLS highest salary was $43,167 in 2019, $39,524 in 2020, and $42,851 in 2021.

starting salary

• 2019: $29,438
• 2020: $30,152
• 2021: $33,391

average annual salary

• 2019: $35,321
• 2020: $33,669
• 2021: $35,623

highest salary

• 2019: $43,167
• 2020: $39,524
• 2021: $42,851

Note: 19 organizations reported starting and annual salary, 18 reported highest salary.

Summary of Direct Support Professional and Frontline Supervisor Trends Over Time

While none of these 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 in light of the pandemic in 2020 that persisted in 2021.

For DSPs, prior to the pandemic (2018-2019), annual turnover was trending down but went back up in 2021. Early turnover within 0-6 months and turnover within 6-12 months of being hired went down over time. DSP vacancy was consistent in 2018 and 2019 and went up in 2020 where it was consistent in 2021. DSP starting, hourly and highest wages went up in each year.

For FLSs, turnover and vacancy rate were flat. Early turnover within 0-6 months of hire initially went down but then rose back up while turnover within 6-12 months of hire went down. FLS starting salaries went up, but annual and highest salaries were flat.

Overview of Training and Consultation Activities

The Employment and Community First CHOICES Workforce QuILTSS Initiative through TennCare, the University of Minnesota, and Tennessee Community Organizations (TNCO) aimed to use a multi-prong approach to addressing workforce challenges in Tennessee. This approach combined a competency- based training program through the QuILTSS Institute with aligned financial resources that included increased wages for achieving higher levels of competency and incentives for providers and capacity building supports provided by the University of Minnesota’s workforce development team. Capacity building activities focused on using the data and information collected through the annual workforce survey to identify and implement strategies to address workforce challenges in organizations while developing a community of practice for sharing effective workforce strategies across the state and a workforce coach training model to support sustainability in Tennessee, that has since been continued by the current MCOs. Figure 23 summarized the key components of the training and consultation activities.

A grey circle with the text Tennessee Community of Practice for Workforce Initiatives surrounded by blue boxes describing elements of the work:

• Implementing a survey and using data to inform practice
• Providing technical consultation with organizations to identify promising strategies based on data
• Delivering a toolkit and training aimed at teaching knowledge and skills for implementing promising workforce strategies
• Developing coaches who can use the technical assistance consultation model to address current and future workforce efforts

During 2021, key training and consulting activities included enhancing understanding on how to use survey report data to identify and assess workforce challenges and select workforce solutions strategies based on an organization’s data. Additionally, ongoing technical consultation and coaching with the participating organizations was provided on selecting and implementing, workforce strategies. Organizations who completed the year 4 workforce survey or completed a previous survey and had not yet received technical assistance were a part of Cohort 3. Ten provider organizations participated in an initial 2-session kickoff workshop designed to understand their workforce data and begin to identify and assess workforce challenges in their respective organizations. Organizations were provided with access to the web-based DSP workforce toolkit and a series of 13 webinars on promising strategies in recruitment, selection, training and retention. Starting in 2021, consultation and training activities were transitioned to Tennessee workforce coaches from three Managed Care Organizations (MCOs) (Amerigroup, UnitedHealthcare, and BlueCare TN) in Tennessee. Workforce coaches from the three Managed Care Organizations (MCOs) received support from UMN workforce consultants to provide technical assistance, training, and Community of Practice meetings to organizations in Tennessee. Organization workforce coaches continued to work within their respective organization on specific workforce activities as well as supporting the community of practice.

These workforce activities implemented by MCO and organization workforce coaches focused on building organizational and regional capacity to address recruitment and retention efforts across the state. In addition, a workforce development stakeholder group has been established to foster engagement across an extensive array of entities to support the effective recruitment, selection and retention of high qualified DSPs and caregivers. Out of this stakeholder group there have been four task force groups established.

The provider training task force group has established a training series to bring forward resources that the Tennessee provider network can use to assist with their workforce needs. The marketing task force group has worked to build marketing tools for providers to use to advertise for vacant roles and to support their branding opportunities in the community. The education task force is partnering with various groups in Tennessee who support the engagement of secondary and postsecondary student pipeline to assist in solving for some of the workforce needs. The final task force group, Voice of the DSP, works to ensure that we are garnering feedback from our DSPs and caregivers as we continue to shape our strategy.

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 are facing difficulties in recruiting, hiring, and retaining ample Caregivers/DSPs to meet this demand. There was a 56% Caregiver/DSP turnover rate (Figure 13), and a 21% vacancy rate (Figure 12) in 2021. This means that over half of the Caregiver/DSP workforce left their positions in 2021, and about one out of every five Caregiver/DSP positions were vacant. These are both higher than national rates: the DSP turnover rate was 44% and the vacancy rate for full-time staff was 12.3% and for part-time staff was 16.4% (National Core Indicators, 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 et al., 2021a; Pettingell et al., 2022). This was reinforced by organizations participating in training and consultation who shared stories of the unprecedented challenges they were continuing to face in finding and keeping Caregivers/DSPs. Ninety-one percent of organizations reported they were more short staffed in 2021 than before the pandemic. As a result of health and safety precautions, many organizations shifted DSP work schedules, locations, and some staff were furloughed or their positions eliminated (see Table 25).

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). Research has shown that direct and indirect costs related to turnover per DSP that provides HCBS are $3,278, although these data were collected in the early 2000s and have not been adjusted for inflation (Larson et al., 2016). Organizations in this study reported a total of 11,690 Caregivers/DSPs employed in 2021. Using the 25% of the Caregiver/DSP annual salary rule of thumb for cost of turnover and the average overall Caregiver/DSP wage of $12.60 per hour (Figure 8), costs of each Caregiver/DSP who leaves the position may be $6,552. At the rate of $6,552 per Caregiver/DSP, a 56% Caregiver/DSP annual turnover rate in the state of Tennessee results in an estimated $42,892,012 in costs related to Caregiver/DSP turnover. Eliminating even half of these costs could result in an annual $1,835 bonus per Caregiver/DSP for the 11,690 Caregivers/DSPs reported.

Many Caregivers/Direct Support Professinals leave their positions soon after hire

Of the 56% of Caregivers/DSPs who left their positions in 2021, 57% 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 26 states and the District of Columbia, 29% of DSPs who left their jobs in 2020 left in the first six months, and 19% left in 6-12 months tenure (National Core Indicators, 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 received resources in 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. Some of the topics covered through 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 (National Core Indicators, 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 2021 was 21% (see Figure 12). The 2021 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 2021 was 15% (see Figure 16).

Impact of COVID-19 on Organizations and the Caregiver/Direct Support Professional Workforce

In a national survey of DSPs who provide supports, the COVID-19 pandemic impacted the DSP workforce and the people who receive supports from DSPs (Pettingell et al., 2022). Similar to these results, Caregivers/DSPs in Tennessee experienced positions which shifted schedules or changed work hours, locations or settings shifted, and some staff were furloughed, or positions eliminated (Table 25). With notable cause for concern, ninety-one percent of organizations reported they were even more short staffed than before the pandemic. The staffing crisis in existence prior to the pandemic was exacerbated as organizations responded to the plethora of challenges brought on by COVID-19.

In terms of incidence of COVID-19 infections among Caregivers/DSPs and people supported, the average rate of infection in organizations for both groups was 16%. There was also incidence of death from COVID-19 among Caregivers/DSPs (<1% on average in organizations) and people who received supports (2% on average in organizations). Resources and continued support are needed for this workforce who are dealing with grief of losing people supported and coworkers, responding to additional health and safety measures, and managing the impact of COVID-19 in their daily work. When asked about the training provided to new Caregivers/DSPs, organizations varied in what they provided to new staff. Sixteen percent of organizations said new staff received typical orientation and preservice training, 81% said they received the typical orientation and preservice training as well as safety training related to the pandemic, and 3% said that typical orientation and preservice training were not provided. Some organizations may have struggled in their response to provide such training while also trying to staff unfilled positions and adhere to social distancing guidelines. Support in providing a unified health and safety response may be needed. It is essential that the MCOs and TennCare understand and consider proactive strategies based on what they learned about the effects of the pandemic on all businesses and industry. They will need to continue to consider the added challenges and costs placed on HCBS employers and their capacity to recruit and retain Caregivers/DSPs and FLSs when the wages are even farther below prevailing wages in most communities and the complexity of Caregivers/DSP work has grown even higher in terms of risks and responsibilities.

Low wages and limited benefits

Organizations reported starting and average wages paid to Caregivers/DSPs. Average starting hourly Caregiver/DSP wages were $12.05 per hour. The state average DSP wages were $12.60 per hour. These wages are very low. The average starting and average hourly wages for DSPs nationwide in 2020 were $12.72 and $13.61, respectively (National Core Indicators, 2022). The average DSP who works 2,000 hours per year would gross only $25,200. The poverty line for a family of three in 2021 was $21,960 (US Health and Human Services, 2021). 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 (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 to provide incentives for professional development may influence the trajectory of this continued low wage trend.

Organizations reported whether or not they provided salary augmentations to Caregivers/DSPs who worked during the COVID-19 pandemic, due to the increased risk of exposure to the virus. Fifty-eight percent of organizations paid salary augmentations related to the pandemic to their Caregivers/DSPs in 2021. The augmentations were most frequently a $0.01 to $1.00 per hour increase (29%) or a lump sum bonus (24%) (Figure 18). Caregivers/DSPs were classified as essential workers during the COVID-19 pandemic, but not all Caregivers/DSPs have benefitted from hazard pay due to the risks they have taken during the pandemic. Further consideration to increasing wages paid to Caregivers/DSPs commensurate with the risks of providing human services in the midst of a pandemic is needed.

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 48% of organizations offered paid time off to some or all of their Caregivers/DSPs; 18% offered paid sick leave and 23% 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 to supporting this workforce. Providing paid leave for employees who have been exposed to COVID-19 and to access COVID-19 vaccinations are also important strategies for managing the spread of the virus.

Fifty-six 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 30% of Caregivers/DSPs used the benefit. Organizations reported that the average cost of health insurance for an individual Caregiver/DSP was $156 per month, with average costs more than tripling for single plus 1 coverage and increasing more than five times for family coverage (Table 7). The cost of health insurance may simply be too high for Caregivers/DSPs to afford the benefit alongside of 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 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 a 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 2021. Across the state, the average number of overtime hours that organizations paid out to Caregivers/DSPs in 2021 was 26,930, and the total number of overtime hours paid out in 2021 was 2,881,536 (Figure 10). The average cost of Caregiver/DSP overtime in 2021 was $179,331, and the total cost of Caregiver/DSP overtime in 2021 was $18,471,076 (Figure 11). Reducing overtime costs by filling vacancies allows providers 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 providers are able to pay more to Caregivers/Direct Support Professionals, 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, particularly for those who work in more individualized settings, 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. Forty-one percent of FLSs left their positions in 2021, with 28% of those frontline supervisors leaving with 0-6 months of hire (Figure 15). There was a 15% 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 DSPs in addition to reducing 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 2021. Certain pieces of data were collected across 17 service types, but some organizations reported that it was difficult or impossible to delineate data across the service types. Participating organizations indicated that 60% of Caregivers/DSPs provide services across service types, and most organizations (83%) pay Caregivers/DSPs the same wages when they work across service types (85% for the East region, 80% in the Middle region, and 84% for the West region).

Recommendations

Survey and Data Collection

In order 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.

We should reflect on and consider the composition of the sample. There are currently two groups of interest included in the year four sample: the original organizations supporting primarily the ECF CHOICES population from the previous three years and the newly identified organizations supporting primarily the CHOICES population from the aging and disability sectors added in year four.

It is important to establish a representative and stable sample. The first three years of the survey had the same sample of organizations supporting primarily the ECF CHOICES populations. For those organizations that took multiple surveys, trends over time were examined for the main outcomes of retention and wages. To accurately describe and understand workforce issues, a representative sample of the organizations providing supports to both populations needs to be grown. The MCOs are working toward this with the goal of adding organizations over time. This means that it will take a few years to establish a representative and stable sample - one where trends over time can be examined.

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. Establishing accurate contact information is a first step of high importance. While the CEO or lead executive may want to be included on communications, this individual is rarely the one who actually assembles and submits the data. Best practice is to assign one person as the primary survey/data collection contact. That person will be responsible for making sure that their data are assembled (data collection sometimes happens by multiple people within the organization - HR office, benefits office, financial office) and submitted on time. Additionally, establishing accurate contact information should begina few months before the survey is launched. It is not uncommon for several communications to happen before the correct contact person is found. Follow-up with organizations needs to be thorough and 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. When organizations are contacted, it is extremely important to verify that they received the survey, that their questions are answered, to remind them of the importance of their voice, and to encourage 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.

Lastly, in order to better understand change in trends over time, it is worth considering a system to track strategies and interventions organizations have implemented to address retention issues (e.g., time spent using technical assistance, training initiatives, etc.). If such interventions are captured in the data, this information can provide context for explaining trends and changes.

Ongoing Support for Provider Organizations in Workforce Development

It is important to continue to support capacity building activities through MCO workforce development efforts. 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. As described previously, by systematically providing targeted technical assistance using best practices in the workforce development and tracking these efforts, organizations can begin to use their annual workforce data to measure and evaluate with fidelity their recruitment and retention efforts.

As previously reported, 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. The MCOs have continued many of the opportunities that produced results for the providers and have created ongoing components to support continued growth. Providing financial incentives to organizations for implementing evidence-based and best practices in workforce recruitment and retention and financial incentives for specific workforce and quality of life outcomes could increase the number of organizations interested in receiving help with recruitment and retention efforts.

Implementation of Competency Based Training and Wage Incentives Model

In 2021, organizations provided feedback on the training content they need for Caregivers/DSPs in their organization. It would be worth continuing to explore what kind of training organizations and Caregivers/DSPs is needed to improve Caregiver/DSP knowledge, skills and abilities and use this feedback to inform processes for developing and implementing a statewide competency-based training and wage incentives model. In addition to exploring expansion of the Direct Support Professional Apprenticeship for developing a workforce pipeline 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. 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 and vacancy rates continue to be high in Tennessee, indicating a need for further training for FLSs. 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 and it is unclear whether competency-based training is advised in state policy for training requirements. Competency-based training for FLSs is important and 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 FLSs. Other resources include The College of Frontline Supervision, Management and Leadership, a national competency-based training curricula for FLSs and NADSP’s Frontline Supervisor Training. 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

Vacancy rates remain high in Tennessee, indicating the need to attract new people to the Caregivers/DSP workforce. Additionally, turnover within the first six months is high, which results in costly training expenses for employees who do not stay around. TennCare, in partnership with the University of Minnesota, created public service announcements, targeted marketing, directed at new applicants entering the workforce. These tools can 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. They also created a TN specific realistic job preview for organizations to incorporate into their hiring and selection processes. Following the recruitment of new applicants, organizations should use realistic job previews 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.

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

Evaluate the Effects of COVID-19 Pandemic on the Workforce

It is clear that the COVID-19 pandemic continued to cause sustained challenges for providers that affect their workforce and ability to recruit and keep Caregivers/DSPs and FLSs. It is important to have a comprehensive understanding of provider, Caregivers/DSP, and FLS experiences throughout the COVID-19 pandemic and their needs for supports as the country continues to navigate pandemics. Nearly every business and industry (especially retail, manufacturing and service industries) has been hit hard by the pandemic and finding and retaining well-trained workers continues to be a major problem in many industries. Other industries have the ability to leverage capital by increasing prices to offset the costs of increased wages for new hires and existing employees. The HCBS provider industry cannot do this. Having a clear picture and understanding of the business context in which providers are trying to sustain a workforce is essential. Ongoing consideration of reimbursement rates and incentives is needed to help keep providers solvent and to pay Caregivers/DSPs and FLSs wages that are comparable to other similar industries.

Conclusion

This survey is part of a comprehensive project to learn about and support the direct support workforce in Tennessee. This fourth annual survey report includes important findings to inform data-driven solutions to support organizations to recruit, hire, and retain Caregivers/DSPs. These data, paired with training and consultation on workforce solutions that is 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. These data provide an additional data point about the status of the Caregiver/DSP workforce issues among the 131 participating organizations.