Tennessee LTSS Workforce Quality Improvement Survey 2023

The Institute on Community Integration (ICI) at the University of Minnesota worked in collaboration with Wellpoint, UnitedHealthcare, BlueCare TN, and TennCare to develop and administer the Quality Improvement in Long Term Services and Supports Workforce Initiative 2024 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. This initiative has been underway for seven years, beginning with an initial three-year phase focused on the direct support workforce serving individuals with intellectual and developmental disabilities (IDD). As part of this comprehensive effort, data gathered from the survey is 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 IDD, physical disabilities, and older adults in Tennessee. During the initial 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 Tennessee Workforce Development Teams to identify and address at least one key challenge that their organization faces to improve their direct support workforce turnover and retention rates. This work expanded in years 4 to7 to include paid Caregivers for people with physical disabilities and older adults and was renamed the Tennessee LTSS Workforce Quality Improvement Initiative.

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

Project technical assistance team from the University of Minnesota included: Heather Barcikowski, Sandra Pettingell, and Yi-Chen Wu.

Report layout and design by Sarah Curtner.

Suggested Citation:

• Pettingell, S., Barcikowski, H., Bershadsky, J., & Wu, Y. (2025). Tennessee LTSS Workforce Quality Improvement Survey 2024 Year Seven Report. Minneapolis: University of Minnesota, Institute on Community Integration.

Background

We are at a time in the history of community living where the need for a stable, competent, and reliable direct support workforce is critically needed. This is true in Tennessee and every state and territory in the United States. Caregivers/DSPs also rely on stable and competent frontline supervisors (FLSs) who set performance expectations and guide and direct their work. Caregivers/DSPs are essential in supporting people with intellectual and developmental disabilities (IDD), people with physical disabilities, and older adults to live, work, develop new and maintain relationships with family and friends, and have good lives in their communities.

For over 30 years, high turnover and vacancy rates for the direct support profession have been documented in the United States (National Core Indicators Intellectual and Developmental Disabilities, NCI-IDD, 2024). These issues and the high stress of the job duties for direct support professionals have been persistent (Bogenschutz et al., 2014; Hall et al., 2022; Hall et al., 2024; Houseworth et al., 2020; PHI, 2021) and will continue to be. The COVID-19 pandemic exacerbated these challenges (Sheppard-Jones et al., 2022). Through the Tennessee’s Quality Improvement in Long-Term Services and Supports Initiative, steps have been taken to understand these workforce challenges specific to Tennessee to implement strategies at the employer and state-wide levels to address these challenges. Progress has been made, but these issues will continue to exist and systems-level support and funding to continue to address these workforce challenges will be essential. There are no easy fixes, and it is imperative to continue to strive toward improving the well-being and stability of Caregivers/DSPs.

Caregivers/DSPs provide vital services and supports for older adults and people with disabilities, including people with IDD, so that they can live, work, and be fully engaged in their community. Caregivers/DSPs are defined as paid workers who spend at least 50% of their time providing direct support to older adults and people with disabilities 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, residential aide, life skills instructor, job coach, home health aide, personal care assistant, and others. Nursing and other professionally licensed staff (e.g., LPNs and RNs) are not considered Caregivers/DSPs for the purposes of this initiative. On-call Caregivers/DSPs (i.e., those who do not have any regularly scheduled hours) are reflected in a question specific to on-call staff.

Caregiver: A Caregiver is a paid worker whose primary responsibilities include helping clients to maintain independence, providing personal assistance with Activities of Daily Living (ADLs) [dressing, grooming, toileting, personal hygiene, eating, and basic clinical tasks (helping with prescribed exercises, administering medication, monitoring vital signs, etc.)], assisting with housekeeping, grocery shopping and cooking, accompanying clients to doctor appointments or other errands, companionship, providing support in community engagement, day centers or other day activities, and respite support to older adults and/or individuals with physical disabilities. Certified Nursing Assistants (CNAs) are included IF the nursing care they provide is basic (monitoring vital signs, cleaning wounds, helping with prescribed exercises, applying or changing bandages, or administering medications).

Direct Support Professional (DSP): A DSP is a paid worker whose primary responsibilities include providing support, guidance, personal assistance, or help with skills development during any activity or at any location (e.g., at work, at home, leisure activities, recreational activities) to adults with intellectual and developmental disabilities (IDD). They may have titles such as Direct Support Workers (DSWs), Personal Care Assistants (PCAs), Employment Specialists (job coaches), Home Health Aides (HHAs), Community Integration Specialists, and many other titles. Direct support work is their primary job responsibility and at least 50% of their hours are spent in direct support tasks doing direct support work.

In Tennessee and across the U.S., the State Medicaid Agency goals include increasing the use of HCBS programs to address waiting lists for services and decreasing the number of people in institutional settings. Without strategic efforts to ensure an adequate number of Caregivers/DSPs are available to provide community services, these goals cannot be met. Older adults and people with disabilities who experience greater Caregiver/DSP turnover suffer more injuries and instances of abuse and neglect. The health and safety of people with disabilities improves when Caregivers/DSPs have longer tenure (Friedman, 2021a). It is important to have timely and effective solutions to the Caregiver/DSP workforce shortage that are available, funded, and continually evaluated so that older adults and people with disabilities have fulfilling experiences in community living (President’s Committee for People with Intellectual Disabilities [PCPID], 2024).

Workforce data is needed from providers, programs, and states to identify and match workforce solutions to recruit and retain Caregivers/DSPs in organizations that provide services and supports to older adults and people with disabilities. Workforce solutions, such as ongoing staff development, can significantly strengthen the services of an organization as well as the safety and health of those they serve (Friedman, 2021b). To positively impact the workforce crisis, organizations need to learn skills to improve their recruitment, selection, and retention of Caregivers/DSPs (PCPID, 2024).

Tennessee’s state Medicaid program, TennCare, 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 older adults and 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. 2024 was the seventh year of the Tennessee LTSS Workforce Quality Improvement Survey (formerly the QulLTSS Initiative Survey), which was completed by disability and aging provider organizations that deliver primarily Employment and Community First CHOICES and CHOICES (Non-ECF CHOICES) in Tennessee and employ Caregivers/DSPs. This report presents a summary of data from 118 provider organizations that completed the 2024 survey regarding their workforce in those programs.

Year Seven Methodology

Year Seven Survey Development & Administration

The Year 7 survey (using calendar year 2024 data) was updated after the year 6 cycle. It was approved by TennCare and the Managed Care Organization (MCO) leads from Wellpoint, BlueCare TN, and UnitedHealthcare. The finalized survey was converted into an online Qualtrics survey. An internal pilot test was conducted to ensure the online survey functionality. The Year 7 survey launched on June 2, 2025. A webinar was delivered on June 10, 2025, for all organizations invited to complete the Year 7 survey. The purpose of the webinar was to introduce the survey, clarify issues that were more difficult for participants in previous years, and answer questions. It was recorded and made available on demand on the TennCare Workforce Initiative website 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 25, 2025.

Recruitment, Sample, and Response Rate

Wellpoint, BlueCare TN, and UnitedHealthcare MCOs provided a list of 468 organizations that employ Caregivers/DSPs and participate in ECF CHOICES/1115 Wavier and/or CHOICES (Non-ECF CHOICES)/1115 Waiver. Of those, 49 (11%) did not meet the qualification criteria which left a sample of 419. Wellpoint, BlueCare TN, and UnitedHealthcare MCOs verified the organization address, primary contact person, and contact information for that primary contact person. The UMN staff drafted an invitation letter to the providers included in the sample frame. The letter was edited, approved, and distributed by Wellpoint, BlueCare TN, and UnitedHealthcare. The purpose of the letter was to make the organizations aware of the survey, its purpose, the timing of data collection, how the data would be used and helpful to them, and to encourage their participation.

Of the 419 Year 7 participants, 118 (28%) submitted a survey, 59 (14%) started the survey, 220 (53%) did not respond at all, and 14 (3%) declined to participate. Of the 118 submitted surveys, 20 (17%) participated in the Year 1 survey, 31 (26%) participated in Year 2, 29 (25%) participated in Year 3, 52 (44%) participated in Year 4, 61 (52%) participated in Year 5, 68 (58%) participated in Year 6, and 34 (29%) were new participants. The analytic sample for the Year 7 data was 118 organizations.

Organizations were grouped into three regions for the regional analysis. Regional analyses were conducted based on the region where the organization provided the highest percentage of their services, which may differ from the location of their administrative/corporate/central office.

Of the 116 organizations who provided some data on region, 32 (28%) provided their highest percentage of service in the East counties, 50 (43%) provided their highest percentage of service in the Middle counties, and 34 (29%) provided their highest percentage of service in the West counties. There were 5 organizations that did not provide information on percent of services offered within each region and 2 organizations that provided an equal number of services in multiple regions meaning there was no highest region. In both instances, the home office item was assigned as their highest region of services. Two organizations were unable to be assigned to a region as there was no information provided.

118 organizations submitted the Year 7 survey reporting on calendar year 2024.

Year Seven Results

This project includes organizations that provide data on the services and supports they offer in the IDD and aging and disability sectors. Years 1, 2, and 3 focused solely on the sector of workforce providing services to individuals with IDD. Year 4 introduced providers in the aging and disabilities sector. So caution should be taken when examining trends over time because the samples are different across time.

This report provides an overview of state-level workforce data gathered from this survey. State and regional data profiles are available in Appendix A. Survey items were analyzed by region when there was a large enough sample size. Regional breakdowns were based on where the organization’s highest percentage of services were located. Unless otherwise specified, responses to survey questions reflect calendar year 2024. It is important to note that while 118 organizations submitted the Year 7 survey, not all organizations answered all questions.

Organization Background

For the purposes 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 East: 28%
• Tennessee Middle: 42%
• Tennessee West: 30%

Figure 1 indicates the percentage of services that 113 organizations provided in the East, Middle, and West regions of Tennessee. In the state, 28% of organizations provided services in the East region, 42% provided services in the Middle region, and 30% provided services in the West region.

When examining administrative office locations, 24% of organizations (28) were headquartered in the East region, 47% (54) in the Middle region, and 29% (34) in the West region. Most organizations (81%) operated in a single region, while 11% served two regions and 8% provided services across all three regions.

Service Areas

Organizations provided services across DDA Waiver/1915c Waiver, ECF CHOICES/1115 Waiver, CHOICES (Non-ECF CHOICES)/1115 Waiver, and VR services. As seen in Figure 2, of the 114 reporting organizations, 68% provided CHOICES (Non-ECF CHOICES)/1115 Waiver, 60% ECF CHOICES/1115 Waiver, 60% DDA Waiver/1915c Waiver, and 15% Vocational Rehabilitation. Additionally, 40% of organizations provided 1 service, 27% two services, 23% three services, and 11% all four services. The average number of services provided was 2 (SD = 1 service). The number of services provided ranged from 1 to 4.

• CHOICES (Non-ECF CHOICES)/1115 Waiver (77): 68%
• ECF CHOICES/1115 Waiver (68): 60%
• DDA Waiver/1915cWaiver (68): 60%
• Vocational Rehabilitation (17): 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.

On average, organizations have been in business delivering services to people with disabilities for 21 years (SD = 19 years) with a range of 0 to 72 years.

Supports Provided

Figure 3 summarizes the supports provided by the organizations to people with disabilities across the state. Statewide, 48% of organizations provided residential supports, 87% in-home supports, and 49% non-residential supports.

• residential supports: 48%
• in-home supports: 87%
• non-residential supports: 49%

In the East region, 56% of organizations provided residential supports, 78% in-home supports, and 75% non-residential supports. In the Middle region, 48% of organizations provided residential supports, 90% in-home supports, and 42% non-residential supports. In the West region, 35% of organizations provided residential supports, 91% in-home supports, and 35% non-residential supports.

People Served

• DDA = Department of Disability and Aging
• ECF CHOICES = Employment and Community First CHOICES
• CHOICES (Non-ECF CHOICES) = Non-Employment and Community First CHOICES
• VR = Vocational Rehabilitation

Across the state, the average number of people for whom organizations provided DDA Waiver/1915c Waiver, ECF CHOICES/1115 Waiver, CHOICES (Non-ECF CHOICES)/1115 Waiver, and/or VR services was 80 people (range 1 to 849). The average number of people served in the East region was 116 (range 4 to 849) in 32 organizations. The average number of people served in the Middle region was 69 (range 2 to 460) in 49 organizations. The average number of people served in the West region was 67 (range 1 to 287) in 33 organizations.

Organization Staffing

The organizations who responded to the survey supported a total of 9,299 people who are aging, have physical disabilities, or intellectual and developmental disabilities (I/DD) and employed a total of 10,806 Caregivers/DSPs and 1,268 FLSs as seen in Figure 4.

In the East region, there were 3,719 people served by 32 organizations with supports from 3,866 Caregivers/DSPs and 434 FLSs. In the Middle region, there were 3,360 people served by 49 organizations with supports from 3,544 Caregivers/DSPs and 287 FLSs. For the West region, there were 2,196 people served by 33 organizations with supports from 3,325 Caregivers/DSPs and 538 FLSs.

• people served: 9,299
• caregivers/DSPs: 10,806
• FLSs: 1,268

Organizations were asked to report the number of full-time, part-time, and on-call Caregivers/DSPs they employ. Most organizations defined their part-time and full-time positions by the number of hours worked per week. Of the 113 organizations who reported, the average number of hours per week a Caregiver/DSP needed to work to be considered full-time was 34 (SD = 8 hours) with a range of 0-80 hours.

At the state-level, 56% of Caregivers/DSPs were full-time, 39% were part-time, and 5% were on-call/temporary or relief staff. Fifty 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: 5%
• part-time: 39%
• full-time: 56%

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

• In the East region, 63% were full-time, 31% were part-time, and 6% were on-call/temporary or relief staff. Fifty-one percent of the Caregivers/DSPs worked across more than one service type.
• In the Middle region, 59% were full-time, 36% were part-time, and 5% were on-call/temporary or relief staff. Fifty-seven percent of the Caregivers/DSPs worked across more than one service type.
• In the West region, 43% were full-time, 52% were part-time, and 5% were on-call/temporary or relief staff. Thirty-seven percent of the Caregivers/DSPs worked across more than one service type.

Caregivers/Direct Support Professionals

Caregiver/Direct Support Professional Wages

Enhanced HCBS federal medical assistance percentage (FMAP) Funds are dollars being used within Tennessee’s Home and Community Based Services (HCBS) Programs—CHOICES (Non-ECF CHOICES)/1115 Waiver, Employment Community First CHOICES (ECF)/1115 Waiver, 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, 2024. 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 $15.10, the overall average wage for all Caregivers/DSPs was $15.79, and the average highest wage for all Caregivers/DSPs was $17.56.

Organizations were asked to report whether Caregivers/DSPs who work in different service types are paid the same wage for each service. Overall, 15% of organizations pay Caregivers/DSPs different wages for different service types. In the East region 10% of organizations pay Caregivers/DSPs different wages for each service type. In the Middle and West regions, the percentages are higher, with 18%, of organizations paying Caregivers/DSPs different wages for each service type.

• starting: $15.10
• average: $15.79
• highest: $17.56

Caregiver/Direct Support Professional Starting Wages

The average starting wage for part-time Caregivers/DSPs was $15.23 (range $12.00 to $19.00). The average starting wage for full-time Caregivers/DSPs was $15.43 (range $12.00 to $18.00). The average starting wage for Caregivers/DSPs overall was $15.10 (range $10.00 to $18.00). These wages are depicted in Figure 7.

Overall

• State (116): $15.10
• West (32): $14.54
• Middle (50): $15.32
• East (32): $15.26

Full-time

• State (77): $15.43
• West (16): $14.99
• Middle (38): $15.61
• East (22): $15.41

Part-time

• State (72): $15.23
• West (18): $14.65
• Middle (34): $14.48
• East (19): $15.29

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 $15.29 (range $13.00 to $18.00). The average starting wage for full-time Caregivers/DSPs was $15.41 (range $13.82 to $18.00). The average starting wage for all Caregivers/DSPs was $15.26 (range $13.00 to $18.00).
• In the Middle, the average starting wage for part-time Caregivers/DSPs was $14.48 (range $12.00 to $19.00). The average starting wage for full-time Caregivers/DSPs was $15.61 (range $12.00 to $18.00). The average starting wage for all Caregivers/DSPs was $15.32 (range $10.00 to $18.00).
• In the West, the average starting wage for part-time Caregivers/DSPs was $14.65 (range $13.00 to $15.75). The average starting wage for full-time Caregivers/DSPs was $14.99 (range $13.00 to $16.25). The average starting wage for all Caregivers/DSPs was $14.54 (range $10.00 to $15.75).

Average Caregiver/Direct Support Professional Wages

Overall

• State (112): $15.79
• West (30): $15.46
• Middle (49): $15.84
• East (32): $16.03

Full-time

• State (76): $16.26
• West (16): $15.52
• Middle (37): $16.09
• East (22): $17.08

Part-time

• State (70): $15.98
• West (18): $15.82
• Middle (32): $16.00
• East (19): $16.08

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 $15.98 (range $12.50 to $26.95). The average full-time Caregiver/DSP wage was $16.26 (range $12.50 to $35.00). The average overall Caregiver/DSP wage was $15.79 (range $10.00 to $26.95). Figure 8 indicates the part-time, full-time, and overall wages. As with the starting wages, there is some variation in Caregiver/DSP average hourly wages by region.

• In the East, the average wage for part-time Caregivers/DSPs was $16.08 (range $13.82 to $20.00). The average wage for full-time Caregivers/DSPs was $17.08 (range $13.82 to $35.00). The average wage for all Caregivers/DSPs was $16.03 (range $13.82 to $20.00).
• In the Middle, the average wage for part-time Caregivers/DSPs was $16.00 (range $12.50 to $22.00). The average wage for full-time Caregivers/DSPs was $16.09 (range $12.50 to $20.00). The average wage for all Caregivers/DSPs was $15.84 (range $10.00 to $21.00).
• In the West, the average wage for part-time Caregivers/DSPs was $15.82 (range $13.75 to $26.95). The average wage for full-time Caregivers/DSPs was $15.52 (range $14.88 to $17.12). The average wage for all Caregivers/DSPs was $15.46 (range $11.00 to $26.95).

Highest Caregiver/Direct Support Professional Wages

Overall

• State (115): $17.56
• West (32): $17.50
• Middle (50): $17.20
• East (31): $18.32

Full-time

• State (74): $18.07
• West (17): $18.94
• Middle (35): $17.47
• East (21): $18.49

Part-time

• State (67): $16.98
• West (17): $17.15
• Middle (31): $16.99
• East (18): $16.82

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 $16.98 (range $12.50 to $30.00). The average highest wage for full-time Caregivers/DSPs was $18.07 (range $12.50 to $32.58). The average highest wage for all Caregivers/DSPs was $17.56 (range 10.00 to $32.58). 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 $16.82 (range $13.82 to $20.75). The average highest wage for full-time Caregivers/DSPs was $18.49 (range $15.00 to $30.29). The average highest wage for all Caregivers/DSPs was $18.32 (range $15.00 to $30.29).
• In the Middle, the average highest wage for part-time Caregivers/DSPs was $16.99 (range $12.50 to $23.00). The average highest wage for full-time Caregivers/DSPs was $17.47 (range $12.50 to $22.07). The average highest wage for all Caregivers/DSPs was $17.20 (range $10.00 to $22.07).
• In the West, the average highest wage for part-time Caregivers/DSPs was $17.15 (range $14.00 to $30.00). The average highest wage for full-time Caregivers/DSPs was $18.947 (range $15.00 to $32.58). The average highest wage for all Caregivers/DSPs was $17.50 (range $12.00 to $32.58).

Caregiver/Direct Support Professional Wage Increases & Bonuses

Organizations were asked to report on whether they provided wage increases to Caregivers/DSPs during calendar year 2024. Additionally, organizations reported on whether they provided different types of bonuses to Caregivers/DSPs.

Hourly Wage Increases

Organizations were asked whether they gave hourly wage increases for Caregivers/DSPs. The percentages for each are in Table 1.

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 2024. Statewide, 49% of organizations provided an hourly wage increase to Caregivers/DSPs for longevity. In the East region, 47% of organizations gave these hourly wage increases, 46% in the Middle region, and 52% in the West region.

Wage increases tied to performance. Organizations were asked whether Caregivers/DSPs earned hourly wage increases tied to performance in 2024. Statewide, 46% of organizations provided an hourly wage increase to Caregivers/DSPs tied to performance. In the East region, 41% of organizations gave these hourly wage increases, 50% in the Middle region, and 42% in the West region.

Cost of living increases. Organizations were asked whether Caregivers/DSPs earned hourly wage increases for cost of living in 2024. Statewide, 46% of organizations provided an hourly wage increase to Caregivers/DSPs for cost of living. In the East region, 63% of organizations gave these hourly wage increases, 34% in the Middle region, and 27% in the West region.

Market-competitive adjustments. Organizations were asked whether Caregivers/DSPs earned hourly wage increases for market-competitive adjustments in 2024. Statewide, 36% of organizations provided an hourly wage increase to Caregivers/DSPs market-competitive adjustments. In the East region, 38% of organizations gave these hourly wage increases, 40% in the Middle region, and 27% in the West region.

Continuing education/Competency-based training. Organizations were asked whether Caregivers/DSPs earned hourly wage increases for continuing education/competency-based training in 2024. Statewide, 22% of organizations provided an hourly wage increase to Caregivers/DSPs for continuing education/competency-based training. In the East region, 22% of organizations gave these hourly wage increases, 24% in the Middle region, and 18% in the West region.

Wages increases implemented to enhance employee retention. Organizations were asked whether Caregivers/DSPs earned hourly wage increases tied to performance in 2024. Statewide, 48% of organizations provided an hourly wage increase to Caregivers/DSPs tied to performance. In the East region, 41% of organizations gave these hourly wage increases, 48% in the Middle region, and 52% in the West region.

Other wage increases. The survey also asked organizations if they offered hourly wage increases to Caregivers/DSPs for reasons not listed in 2024. Statewide, 14% of the organizations provided wage increases for other reasons. In the East region, 16% of organizations gave these hourly wage increases, 14% in the Middle region, and 12% in the West region. Organizations were asked to specify the other reasons they provided hourly wage increases. The other reasons included:

• Annual increase
• Holiday bonus
• DDA pay increase only
• Funds provided by state
• Mandatory increase (state mandate, TennCare requirement)
• Status/Position change (i.e., Residential DSP to Residential DSP Manager)

Caregiver/Direct Support Professional Bonuses

Organizations were asked whether they gave full-time Caregivers/DSPs monetary bonuses. The percentages for each are in Table 2.

Employee referral bonus. Organizations may give referral bonuses to current employees to encourage recruitment. The employees share information about the work with people they know whose skills and interests are a good fit for the position. The referral bonus is generally given to the employee after the new hire remains in the position for a specified amount of time to ensure qualified, interested individuals are recruited. Statewide, 54% of organizations gave a referral bonus to Caregivers/DSPs across the state. By region, 59% of organizations provided referral bonuses in the East, 49% provided referral bonuses in the Middle, and 55% of organizations provided referral bonuses in the West.

Hiring bonus. A hiring bonus is generally provided to the newly hired employee as an incentive to attract individuals to the organization. Typically, part of the hiring bonus is paid shortly after hire, and part is paid at a specified time after hire. Statewide, 25% of organizations provided a hiring bonus to newly hired Caregivers/DSPs. By region, 28% of organizations provided hiring bonuses in the East, 25% of organizations provided hiring bonuses in the Middle, and 21% of organizations provided hiring bonuses 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.). Statewide, 36% of organizations gave a bonus to Caregivers/DSPs for years of service across the state. By region, 34% of organizations provided years of service bonuses in the East, 37% of organizations provided years of service bonuses in the Middle, and 36% of organizations provided years of service bonuses in the West.

Performance recognition bonus. Performance recognition is when employees are rewarded for their behavior, effort, or achievement that is above expectation and supports the organization’s mission, vision, and values. Statewide, 47% of organizations gave a performance recognition bonus to Caregivers/DSPs. By region, 56% of organizations provided performance recognition bonuses in the East, 43% of organizations provided performance recognition bonuses in the Middle, and 39% of organizations provided recognition bonuses in the West.

Continuing education/Competency-based training. Statewide, 17% of organizations gave a monetary bonus for continuing education/competency-based training to Caregivers/DSPs. By region, 25% of organizations provided a bonus for continuing education/competency-based training in the East, 16% of organizations provided a bonus for continuing education/competency-based training in the Middle, and 9% of organizations provided a bonus for continuing education/competency-based training in the West.

Other bonuses. Statewide, 20% of organizations provided bonuses to Caregivers/DSPs for reasons other than employee referral, hiring, years of service, or performance recognition bonuses. By region, 19% of organizations provided a bonus for other reasons in the East, 18% of organizations provided a bonus for other reasons in the Middle, and 24% of organizations provided a bonus for other reasons in the West. Organizations were asked to specify the other reasons they provided bonuses. The other reasons they provided were:

• Annual increases
• Any employee that refers someone and that employee stays on for 90 days with no call ins, the referrer received $100
• Efficiency premium for clocking in/out & submitting all documentation
• End of year bonus
• Highly qualified caregiver program bonus (monthly, quarterly)
• Holiday/seasonal bonus
• Local premiums based on branch and service location
• NADSP badge completion
• On-call incentive
• Perfect attendance
• Picking up extra shifts.

Caregiver/Direct Support Professional Work Hours and Overtime

Organizations were asked to respond to questions about the number of hours Caregivers/DSPs worked per week and the number of hours of overtime Caregivers/DSPs are working on average. Overtime is a significant cost in the long-term services and support system. Many Caregivers/DSPs rely on overtime to earn a livable wage. In a study of DSPs in Minnesota, 68% of DSPs reported that they would work more hours or overtime if they were available at their primary employer (Hewitt et al., 2019). Nearly 30% of DSPs in that study worked a second job. Depending on settings where services are provided (e.g., residential, in-home, non-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 overtime.

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 3.

Across reporting organizations in the state, Caregivers/DSPs worked an average of 39 (range 5 to 87) hours per week. For organizations who could differentiate between part-time and full-time employees, part-time Caregivers/DSPs worked an average of 26 (range 12 to 65) hours per week and full-time Caregivers/DSPs worked an average of 41 (range 5 to 75) hours per week.

• In the East region across reporting organizations, Caregivers/DSPs worked an average of 39 (range 5 to 87) hours per week. For organizations who could differentiate between part-time and full-time employees, part-time Caregivers/DSPs worked an average of 25 (range 16 to 50) hours per week and full-time Caregivers/DSPs worked an average of 42 (range 5 to 75) hours per week.
• In the Middle region across reporting organizations, Caregivers/DSPs worked an average of 38 (range 8 to 66) 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 12 to 38) hours per week and full-time Caregivers/DSPs worked an average of 41 (range 12 to 66) hours per week.
• In the West region across organizations, Caregivers/DSPs worked an average of 39 (range 20 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 30 (range 14 to 66) hours per week and full-time Caregivers/DSPs worked an average of 39 (range 15 to 50) hours per week.

Caregiver/Direct Support Professional Overtime Hours

Organizations reported overtime hours paid to full-time Caregivers/DSPs in 2024. Figure 10 indicates the overall number of overtime hours paid to full-time Caregivers/DSPs. Statewide, the average number of overtime hours that organizations paid out to full-time Caregivers/DSPs in 2024 was 28,733 (range 0 to 1,032,413). The total number of overtime hours paid out in 2024 by 103 organizations was 2,959,455. In the East region, the average number of overtime hours paid out was 52,411 (range 0 to 1,032,413) with a total of 1,519,909 overtime hours paid to full-time Caregivers/DSPs. In the Middle region, the average number of overtime hours paid out was 9,914 (range 0 to 63,431) with a total of 446,138 overtime hours paid to full-time Caregivers/DSPs. In the West region, the average number of overtime hours paid out was 36,556 (range 0 to 288,000) with a total of 987,008 overtime hours paid to full-time Caregivers/DSPs.

Caregiver/Direct Support Professional Cost of Overtime

A key workforce issue nationwide for organizations that employ Caregivers/DSPs is the high level of Caregiver/DSP overtime hours. As vacancy rates and turnover increase, Caregivers/DSPs are asked to work more hours to fill in those missing employee hours. Overtime can be the conduit 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, combined with the demand for Caregivers/DSPs surpassing the supply of workers, often leads to high burnout rates resulting in inconsistent quality and continuity 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 full-time Caregiver/DSP overtime hours paid out in calendar year 2024, 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 2024. This gives the wage for the extra time – the extra one-half (assuming time and a half pay for extra hours). And, when multiplied by the number of overtime hours, it produces the cost of the extra time.

Statewide, the average cost of Caregiver/DSP overtime in 2024 was $228,787 (range $0 to $7,830,853) for participating organizations. The total cost of Caregiver/DSP overtime in 2024 from 101 organizations was $23,107,507.

• In the East region, the average cost of Caregiver/DSP overtime in 2024 was $409,656 (range $0 to $7,830,853). The total cost of Caregiver/DSP overtime in 2024 from 29 organizations was $11,880,035.
• In the Middle region, the average cost of Caregiver/DSP overtime in 2024 was $80,857 (range $0 to $470,915). The total cost of Caregiver/DSP overtime in 2024 from 44 organizations was $3,557,696.
• In the West region, the average cost of Caregiver/DSP overtime in 2024 was $293,022 (range $0 to $2,179,240). The total cost of Caregiver/DSP overtime in 2024 from 26 organizations was $7,618,575.

The cost of overtime for the state in 2024 is shown in Figure 11.

Caregiver/Direct Support Professional Retention

Caregiver/DSP retention is addressed in this survey by considering vacancy rates, turnover ratio, 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 the aging of the population, changing demographics in the U.S., growth in long-term services and supports, and low unemployment rates that increases demand for workers to fill open positions (Campbell et al., 2021). The response to the COVID-19 pandemic also shifted the landscape in the manner supports are provided and the willingness of workers to fill human service positions (Hewitt et al., 2021). Organizations also reported 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 12%. The average vacancy rate for part-time positions was 17%, and the average vacancy rate for full-time positions was 13%.

• 12% overall vacancy rate
  • 17% of part-time positions were vacant
  • 13% of full-time positions were vacant

• In the East region, the average vacancy rate among full-time Caregivers/DSPs was 14%. The average part-time Caregiver/DSP vacancy rate was 20%. The average vacancy rate among all Caregiver/DSP positions was 11%.
• In the Middle region, the average vacancy rate among full-time Caregivers/DSPs was 14%. The average part-time Caregiver/DSP vacancy rate was 18%. The average vacancy rate among all Caregiver/DSP positions was 13%.
• In the West region, the average vacancy rate among full-time Caregiver/DSP positions was 9%. The average vacancy rate among part-time Caregiver/DSP position in the West region was 15%. The average vacancy rate among all Caregiver/DSP positions was 10%.

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 and departure in the first year of employment (early separation within 0-6 months of hire and turnover within 6-12 months of hire) among full-time, part-time, and all Caregivers/DSPs employed were computed for this report.

Measuring Turnover

The annual turnover ratio is what the national benchmarks for the NCI-IDD (NCI-IDD, 2024) and NCI-AD State of the Workforce Surveys use. Turnover ratio was calculated using two variables: the number of Caregivers/DSPs who left in the past year and the total number of Caregivers/DSPs employed. The formula used to define turnover ratio was:

Statewide, the annual turnover ratio for full-time Caregivers/DSPs in calendar year 2024 was 46%. The turnover ratio among part-time Caregivers/DSPs was 60%. The overall Caregiver/DSP annual turnover ratio was 48%.

• In the East region, the average turnover ratio among full-time Caregivers/DSPs was 53%. Among part-time Caregivers/DSPs, the average turnover ratio was 45%. The average turnover ratio among all Caregivers/DSPs in the East region was 52%.
• In the Middle region, the average turnover ratio among full-time Caregivers/DSPs was 43%. Among part-time Caregivers/DSPs, the average turnover ratio was 69%. The average turnover ratio for all Caregivers/DSPs in the Middle region was 51%.
• In the West region, the average turnover ratio among full-time Caregivers/DSPs was 47%. The average turnover ratio among part-time Caregivers/DSPs was 64%. The average turnover ratio among all Caregivers/DSPs in the West region was 40%.

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

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 percentage of Caregivers/DSPs who left within their first year of employment.

Separation 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:

Statewide, the average Caregiver/DSP separation rate within 0 to 6 months of hire was 47% across all Caregivers/DSPs, 53% for part-time Caregivers/DSPs, and 42% for full-time Caregivers/DSPs.

• In the East region, the average Caregiver/DSP separation rate within 0 to 6 months of hire was 45% across all Caregivers/DSPs, 51% for part-time Caregivers/DSPs, and 47% for full-time Caregivers/DSPs.
• In the Middle region, the average Caregiver/DSP separation rate within 0-6 months of hire was 50% across all Caregivers/DSPs, 61% for part-time Caregivers/DSPs, and 44% for full-time Caregivers/DSPs.
• In the West region, the average Caregiver/DSP separation rate within 0-6 months of hire was 44% across all Caregivers/DSPs, 47% for part-time Caregivers/DSPs, and 34% for full-time Caregivers/DSPs.

Separation 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:

Statewide, the average Caregiver/DSP separation rate within 6 to 12 months of hire was 34% across all Caregivers/DSPs, 32% for part-time Caregivers/DSPs, and 33% for full-time Caregivers/DSPs.

• In the East region, the average Caregiver/DSP separation rate within 6 to 12 months of hire was 28% across all Caregivers/DSPs, 16% for part-time Caregivers/DSPs, and 33% for full-time Caregivers/DSPs.
• In the Middle region, the average Caregiver/DSP separation rate within 6 to 12 months of hire was 34% across all Caregivers/DSPs, 36% for part-time Caregivers/DSPs, and 33% for full-time Caregivers/DSPs.
• In the West region, the average Caregiver/DSP separation rate within 6 to 12 months of hire was 36% across all Caregivers/DSPs, 32% for part-time Caregivers/DSPs, and 34% for full-time Caregivers/DSPs.

• overall turnover: 48%

Of those who left:

• 47% left within 0-6 months of hire
• 34% left within 6-12 months of hire

Reasons Caregivers/Direct Support Professionals Give for Leaving Their Positions

Most of the organizations who participated (69%) track reasons that Caregivers/DSPs give for leaving their position. Organizations were asked to select the reasons that Caregivers/DSPs give for leaving their position. Table 4 shows the percentage of providers in the state and regions that selected each reason. The table is ordered from greatest to least percentage of organizations in the state.

Statewide, organizations reported “No call/No show” (69%) as the most common reason for Caregivers/DSPs leaving their position. “Found another job at another company” (68%) was the second most common reason, and “Was terminated/fired” (64%) was the third most common reason for Caregiver/DSP departure. Other reasons included: “Not a good fit for the type of work” (54%), “Pay too low/Needed better pay” (37%), “Advanced to a new position within the company in a different service” (13%), “Could not get along with co-workers” (8%), “Having too little or poor quality time with their supervisor” (6%), “Training/support was inadequate” (6%), and “Not recognized for the work they did” (1%).

There were some regional differences in percentages of organizations that selected the reasons, but providers selected the same top four reasons in each of the three regions and the state.

Nearly one-quarter (22%) of organizations selected “other” as a reason that Caregivers/DSPs gave for leaving their position. Organizations had the opportunity to write in the “other” reason, which included the following:

• Attendance
• Death [client or Caregiver/DSP or family member]
• Moved/Relocated
• Personal/Family Reasons
• Policy violations
• Resigned/Quit
• Retirement
• Returning to school
• Schedule conflict
• Training incomplete or not done
• They don’t want to work – just want the pay.

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 pooled paid time off (not differentiating between sick leave and paid vacation), paid sick leave, paid vacation, paid personal time, and health benefits to some or all of their Caregivers/DSPs.

As seen in Table 5, statewide, 33% of the reporting organizations offered pooled paid time off (PTO) to some or all Caregivers/DSPs, 25% offered paid sick leave, 36% offered paid vacation, and 28% offered paid personal time.

• In the East region, 47% of the reporting organizations offered pooled paid time off (PTO) to some or all Caregivers/DSPs, 28% offered paid sick leave, 50% offered paid vacation, and 31% offered paid personal time.
• In the Middle region, 22% of the reporting organizations offered pooled paid time off (PTO) to some or all Caregivers/DSPs, 18% offered paid sick leave, 28% offered paid vacation, and 22% offered paid personal time.
• In the West region, 38% of the reporting organizations offered pooled paid time off (PTO) to some or all Caregivers/DSPs, 32% offered paid sick leave, 35% offered paid vacation, and 32% offered paid personal time.

Health Insurance

Statewide, 54% of the 118 reporting organizations offered health insurance to some or all Caregivers/DSPs. On average, the minimum number of hours a Caregiver/DSP had to work per week to be eligible for health insurance was 31 (range 0 to 40 hours). On average, 30% (range 0% to 100%) of Caregivers/DSPs were enrolled in health insurance through their organization.

• In the East region, 63% of the 32 reporting organizations offered health insurance to some or all Caregivers/DSPs. On average, 33% (range 0% to 99%) of Caregivers/DSPs were enrolled in health insurance through their organization.
• In the Middle region, 54% of the 50 reporting organizations offered health insurance to some or all Caregivers/DSPs. On average, 24% (range 0% to 81%) of Caregivers/DSPs were enrolled in health insurance through their organization.
• In the West region, 47% of the 34 reporting organizations offered health insurance to some or all Caregivers/DSPs. On average, 31% (range 0% to 100%) of Caregivers/DSPs were enrolled in health insurance through their organization.

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.

• starting salary: $38,926
• average salary: $43,000
• highest salary: $51,735

Figure 14 shows the average FLS starting, average, and highest salaries. Statewide, the average starting annual salary for FLSs was $38,926 (range $15,000 to $85,000). The overall average annual salary was $43,000 (range $16,000 to $97,500). The average highest annual salary was $51,735 (range $28,000 to $189,000).

• In the East region, the average starting annual salary for FLSs was $41,290 (range $26,390 to $62,400). The average annual salary was $44,133 (range $29,290 to $68,640). The average highest annual salary was $51,561 (range $29,290 to $74,880).
• In the Middle region, the average starting annual salary for FLSs was $38,820 (range $18,000 to $85,000). The average annual salary was $42,718 (range $28,000 to $97,500). The average highest annual salary was $50,888 (range $28,000 to $100,000).
• In the West region, the average starting annual salary for FLSs was $37,244 (range $15,000 to $79,040). The average annual salary was $42,843 (range $16,000 to $79,040). The average highest annual salary was $54,028 (range $30,000 to $189,000).

Frontline Supervisor Retention

FLS turnover is a key issue nationwide that needs addressing to stabilize the direct support workforce. Annual turnover ratio, early separations, and vacancy for all FLSs were computed for this report. FLS turnover ratio and early separation data are shown in Figure 15.

Frontline Supervisor Turnover

FLS annual turnover ratio was calculated using the same method as for Caregivers/DSPs which used two variables: the number of FLSs who left in the last year and the total number of FLSs employed. The annual turnover ratio was defined as:

• overall turnover: 25%

Of those who left:

• left within 0-6 months of hire: 23%
• left within 6-12 months of hire: 27%

Statewide, the average annual turnover ratio for FLSs was 25%. By region, the FLS annual turnover ratio was 16% in the East, 38% in the Middle, and 17% 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 are not effectively prepared to do their job. 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 who rely on them for their support and supervision. Data were gathered to show the percentage of supervisors who left within their first year of employment. High FLS turnover can be a predictor of high Caregiver/DSP turnover because supervisors provide continuity for the Caregivers/DSPs they oversee. Additionally, FLS vacancies can be costly to fill.

Separation 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:

Statewide, the average FLS separation rate within 0 to 6 months of hire was 23%. By region, the average FLS separation rate within 0 to 6 months of hire was 13% in the East, 24% in the Middle, and 31% in the West.

Separation 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:

Statewide, the average FLS separation rate within 6 to 12 months of hire was 27%. By region, the average FLS separation rate within 6 to 12 months of hire was 19% in the East, 44% in the Middle, and 9% in the West.

Frontline Supervisor Vacancy Rate

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

As seen in Figure 16, statewide, the average FLS vacancy rate was 7%. By region, the average FLS vacancy rate was 6% in the East, 8% in the Middle, and 5% in the West.

Revenue & Wage Costs

Statewide, the average total annual revenue for the 102 reporting organizations was $20,782,789 (range $16,000 to $1,450,000,000). The average payroll costs were $7,997,876 (range $12,000 to $318,882,825). Average total administrative costs (all non-program related expenses) were $1,010,313 (range $1,000 to $14,370,575). Average total expenses for training, employee assistance, and staff development were $41,640 (range $0 to $295,000). For the 97 reporting organizations, the average percent of overall revenue derived from rates for ECF CHOICES/1115 Waiver and/or CHOICES (Non-ECF CHOICES)/1115 Waiver directed toward Caregiver/DSP wages was 66% (range 0% to 100%).

Key Workforce Metric Trends Over Time

The examination of key workforce metrics over time is important in understanding where there is stability and where challenges exist. Average values for annual turnover, early turnover, vacancy rates, and wages were examined to see if and how they changed for Caregivers/DSPs and FLSs, respectively, over time.

As with all historical data, caution should be taken with interpretation of the trends over time. It is important to keep in mind that the sample cohort differs, meaning that it does not include all the same organizations every year. Along with changes in the sample each year, other major unanticipated events that could have had an impact on the results. These included a tornado outbreak in March 2020, the COVID-19 pandemic beginning in April 2020, and wage increases that were implemented beginning in Tennessee in 2021. Increasing access to HCBS, strengthening the HCBS workforce, and building provider capacity were outlined in the Tennessee HCBS FMAP funding plan submitted and approved by the Centers for Medicare & Medicaid Services (CMS; Moss, 2022). The pandemic affected organization functioning, specifically staffing and wages. There is no empirical data to understand the impact of these events and other outside factors that may have influenced changes over time.

Caregiver/Direct Support Professional Trends Over Time

Caregiver/DSP Retention Rates

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

Annual Caregiver/DSP turnover ratio tells the percentage of Caregiver/DSPs who left the organization (turned over) in the last year out of all Caregivers/DSPs on staff at the end of 2024. As seen in Figure 17, the average annual turnover in surveyed organizations was 46% in 2018, increased to 63% in 2020 and decreased to 61% in 2022 and 48% in 2024.

Early Caregiver/DSP turnover within 0-6 months of hire tells the percentage of Caregiver/DSPs who left their position within the first 6 months of starting the job. For Caregiver/DSPs, the average early turnover within 0-6 months of hire was 53% in 2019, decreased to 47% in 2020, increased to 61% in 2022, and decreased to 47% in 2024.

Caregiver/DSP turnover within 6-12 months of hire tells the percentage of Caregiver/DSPs who left their position within 6-12 months of starting the job. For Caregiver/DSPs, the average turnover within 6-12 months of hire was 33% in 2019, decreased to 22% in 2020, rose to 28% in 2022, and reached 34% in 2024.

Caregiver/DSP vacancy rate tells the percentage of vacant positions out of all the Caregiver/DSP positions. The average Caregiver/DSP vacancy rate was 15% in 2018, increased to 19% in 2020, and decreased to 17% in 2022 and 12% in 2024.

Turnover

• 2018: 46%
• 2019: 47%
• 2020: 63%
• 2021: 57%
• 2022: 61%
• 2023: 58%
• 2024: 48%

Early turnover (0-6 months)

• 2018: not applicable
• 2019: 53%
• 2020: 47%
• 2021: 57%
• 2022: 61%
• 2023: 55%
• 2024: 47%

Turnover (6-12 months)

• 2018: not applicable
• 2019: 33%
• 2020: 22%
• 2021: 28%
• 2022: 28%
• 2023: 24%
• 2024: 34%

Vacancy

• 2018: 15%
• 2019: 13%
• 2020: 19%
• 2021: 21%
• 2022: 17%
• 2023: 13%
• 2024: 12%

Note: 2018: Turnover and Vacancy N=42; 2019: Turnover and Vacancy N=69; 2020: Turnover N=55 and Vacancy N=56; 2021: Turnover N=106 and Vacancy N=108; 2022: Turnover N=132 and Vacancy N=134; 2023: Turnover N=112 and Vacancy N=107; 2024: Turnover N=111 and Vacancy N=113.

Caregiver/DSP Hourly Wages

Organizations provided data for Caregiver/DSP starting hourly wages, average hourly wages, and highest hourly wages. As seen in Figure 18, Caregiver/DSP hourly wages have increased consistently from 2018 to 2024. The average Caregiver/DSP starting hourly wage was $9.38 in 2018, $10.36 in 2020, $13.21 in 2022, and $15.10 in 2024. The average Caregiver/DSP hourly wage was $10.17 in 2018, $11.09 in 2020, $13.69 in 2022, and $15.79 in 2024. The average Caregiver/DSP highest hourly wage was $12.22 in 2018, $13.20 in 2020, $14.95 in 2022, and $17.56 in 2024.

Starting Hourly Wage

• 2018: $9.38
• 2019: $9.88
• 2020: $10.36
• 2021: $12.05
• 2022: $13.21
• 2023: $14.55
• 2024: $15.10

Hourly Wage

• 2018: $10.17
• 2019: $10.56
• 2020: $11.09
• 2021: $12.60
• 2022: $13.69
• 2023: $15.01
• 2024: $15.79

Highest Hourly Wage

• 2018: $12.22
• 2019: $13.11
• 2020: $13.20
• 2021: $14.47
• 2022: $14.95
• 2023: $16.69
• 2024: $17.56

Note: 2018: n=46; 2019: n=71; 2020: n=61; 2021: n=122; 2022: n=136; 2023: n=108; 2024: n=112.

Frontline Supervisor Trends Over Time

Frontline Supervisor Retention Rates

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

Annual FLS turnover ratio tells the percentage of FLSs who left the organization (turned over) in the last year out of the FLS on staff at the end of 2023. 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 the FLS positions.

As seen in Figure 19, the average FLS annual turnover was 25% in 2019, decreased to 21% in 2020, increased to 41% in 2021, and decreased to 25% in 2024. The average early turnover within 0-6 months of hire was 29% in 2019, decreased to 23% in 2020, increased to 35% in 2022, and decreased to 23% in 2023. The average turnover within 6-12 months of hire was 28% in 2019, increased to 51% in 2021 and 46% in 2022, and decreased to 27% in 2024. The average vacancy rate was 13% in 2019, increased to 16% in 2020 and 22% in 2022, and decreased to 7% in 2024.

Turnover

• 2019: 25%
• 2020: 21%
• 2021: 41%
• 2022: 30%
• 2023: 17%
• 2024: 25%

Early turnover (0-6 months)

• 2019: 29%
• 2020: 23%
• 2021: 28%
• 2022: 35%
• 2023: 32%
• 2024: 23%

Turnover (6-12 months)

• 2019: 28%
• 2020: 29%
• 2021: 51%
• 2022: 46%
• 2023: 28%
• 2024: 27%

Vacancy

• 2019: 13%
• 2020: 16%
• 2021: 15%
• 2022: 22%
• 2023: 6%
• 2024: 7%

Note: 2019: Turnover N=57 & Vacancy N=56; 2020: Turnover N=53 & Vacancy N=50; 2021: Turnover N=90 & Vacancy N=86; 2022: Turnover N=96 & Vacancy N=99; 2023: Turnover=91 & Vacancy N=93; 2024: Turnover=93 & Vacancy N=94.

Frontline Supervisor Salaries

Organizations provided data for FLS starting salary, annual salary, and highest salary. As seen in Figure 20, FLS salaries have consistently increased over time except for 2024. The average FLS starting salary was $31,187 in 2019, increased to $31,552 in 2020, $39,526 in 2023, and decreased to $38,926 in 2024. The average FLS annual salary was $34,670 in 2019, increased to $34,024 in 2020, $43,336 in 2023, and decreased to $43,000 in 2024. The average FLS highest salary was $42,654 in 2019, decreased to $38,731 in 2020, increased to $44,797 in 2022 and $51,735 in 2024.

Starting salary

• 2019: $31,187
• 2020: $31,552
• 2021: $34,180
• 2022: $37,177
• 2023: $39,526
• 2024: $38,926

Average annual salary

• 2019: $$34,670
• 2020: $34,024
• 2021: $36,611
• 2022: $39,469
• 2023: $43,336
• 2024: $43,000

Highest annual salary

• 2019: $42,654
• 2020: $38,731
• 2021: $43,629
• 2022: $44,797
• 2023: $50,809
• 2024: $51,735

Note: 2019: n=65; 2020: n=55; 2021: n=103; 2022: n=117; 2023: n=85; 2024: n=90.

Summary of Key Workforce Metrics Over Time

While none of the trends in retention measures or wages and salaries can be directly attributed to involvement in specific training and consultation activities, there are trends worth noting, especially considering the pandemic in 2020 that impacted the workforce drastically. An additional reminder with interpreting trends over time is that the sample changed annually. Results for each survey year are for those organizations that responded each year. This is important as there was a substantial change to the sample in 2021 when the study expanded to include the CHOICES (Non-ECF CHOICES)/1115 Waiver providers. In addition, in 2024, there were new providers in the network as well.

For Caregiver/DSPs, prior to the pandemic (2018-2019), annual turnover was consistent but rose during the pandemic. It has been decreasing since 2022. Early turnover within 0-6 months crept up over the years but is currently 6% lower than when it was first reported. Turnover within 6-12 months of being hired bounced since 2019 and is 10% higher than 2023. Caregiver/DSP vacancy increased from 15% in 2018 to 21% in 2021 during the pandemic but has dropped consistently since 2022 and is 3% lower than when it was first reported in 2018. Starting, hourly and highest wages have consistently increased annually for Caregiver/DSPs.

For FLSs, turnover increased during the pandemic but has consistently decreased since 2021. Early turnover within 0-6 months of hire increased in 2022 but has dropped to 23% in 2024 which is 6% less than when it was first reported in 2019. For turnover within 6-12 months of hire, there was a spike up to 51% after the pandemic, but rates have consistently dropped since that time. FLS vacancy rates increased from 13% in 2018 to 22% in 2022. However, they dropped dramatically to 7% in 2024. FLS starting, annual, and highest salaries have increased annually, although average starting and annual salaries are slightly lower in 2024.

Tennessee Workforce Development Initiatives Organization Participation

In 2024, MCOs added two questions to the annual survey to gain some insight into the involvement of organizations in the state workforce development initiatives. Of the 116 organizations who answered the question, 60% were involved with or working on Tennessee workforce development initiatives with the MCO workforce development teams. There was a wide range of participation in workforce development opportunities (Table 6). Of the 69 organizations that were involved with the MCO workforce development teams and answered the questions, three-quarters (74%) had implemented recruitment tools. Over 60% had implemented retention tools (65%), met with MCO leads/coaches for consultation (62%), and enrolled in online asynchronous training for Caregivers/DSPs (61%). Over half had attended regional job fairs (58%) and attended statewide workforce development events and/or trainings (54%). Just under half had attended workforce communities of practice and/or roundtables (45%) and implemented selection tools (44%). Nearly one-third (30%) participated in National Alliance for Direct Support Professionals E-Badge Academy, and 15% enrolled in DirectCourse’s College of Frontline Supervision and Management (CFSM). Organizations participated in five workforce development opportunities, on average (range 1 to 10 opportunities).

These numbers are encouraging. Understanding which recruitment, retention, and selection tools have been implemented and how often they are used, the utilization of trainings and credential programs by DSPs and FLSs in organizations, and whether information gained at events, roundtables, communities of practice, and trainings is taken back and applied in practice would be useful. For the 40% of reporting organizations indicating no involvement with the MCO workforce development teams, there is an opportunity to increase their awareness and encourage them to participate in these opportunities to make an impact on their individual workforce stability.

Discussion

Workforce Stability and Quality of Services

The quality of services that older adults and people with disabilities receive is directly impacted by the stability of the direct support workforce. High-quality services are imperative to ensure that older adults and people with disabilities can be a part of their chosen communities in ways that are meaningful to them. A stable and highly competent direct support workforce is needed. However, turnover and vacancy rates remain at high levels for direct support workers across the United States, an issue that has remained notably consistent over a few decades.

Tennessee’s Managed Care Organization (MCO) workforce development teams have made strides in strengthening the direct support workforce. Since 2021, the overall Caregiver/DSP vacancy rate has dropped from 21% to 12% in 2024 (Figure 17) – an improvement that reflects focused recruitment and retention strategies. Similarly, turnover rates have declined from 58% in 2023 to 48% in 2024 (Figure 17), demonstrating progress toward greater workforce stability. While vacancy and turnover rates remain above national averages, these trends show that Tennessee is moving in the right direction. The collaborative efforts of MCO teams and providers are creating a more stable workforce, which is essential for delivering consistent, high-quality services to individuals who rely on long-term supports.

Caregivers/Direct Support Professionals Leave Their Positions Soon After Hire

Of the 48% of Caregivers/DSPs who left their positions in 2024, 47% (down from 55% in 2023) left in the first six months of employment. An additional 34% of those left within six to twelve months of employment (Figure 13). For comparison, in organizations that employ DSPs in 26 states including the District of Columbia, 43.1% of DSPs who left their jobs in 2023 had been employed less than six months, and 23.3% who left had been employed between 6 and 12 months (NCI-IDD, 2024). While early turnover in Tennessee is comparable to national averages and turnover that takes place between 6-12 months is slightly lower in Tennessee than national averages, these are still high rates of Caregivers/DSPs leaving their position soon after starting, especially for providing the personalized, skilled supports required of many Caregivers/DSPs.

High rates of Caregivers/DSPs leaving early in their tenure (in 0-6 months or 6-12 months of hire) may indicate a need for organizations to provide additional supports and training for new staff on the job in conjunction with providing job feedback to develop sufficient skills on the job. It may also be indicative of job candidates entering positions without clear expectations about what the job entails. Without a realistic job preview or clear job description prior to hire, some new hires may be unaware of what the job will require of them and find this work to be a poor fit shortly after starting. Others may leave if there is work available in another industry for similar or better pay. Sixty-four percent of the 69 providers who responded reported using early retention strategies like competency-based orientation and onboarding practices and selection strategies like realistic job previews or structured behavioral interviewing which often help to mitigate early turnover.

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 included hiring practices and using referral bonuses in recruitment, sample job descriptions that align with core competencies, ease of applying through the organization website, realistic job previews and how to incorporate them into the selection process, structured behavioral interview guides, effective orientation, onboarding and peer mentoring and the importance of effective frontline supervision in the first six months in addition to other training topics and resources. Having the goal of reducing their early turnover (within 6 months of hire), organizations who maintain efforts to implement what they have learned can measure the impact on turnover over time.

Reasons for Leaving

Stay interviews, stay surveys, and satisfaction surveys are gaining popularity and recommended by the human resources field to better understand an organization’s workforce, why they stay, and why they might leave in the future (Finnegan, 2023). The most common reason Caregivers/DSPs left in 2024, according to organizations, were “No call/No show”, "Found another job at another company", and "Was terminated/fired". While it is often challenging to gather the reason Caregivers/DSPs leave, organizations can instead work to understand the reasons they stay and build on those positive attributes by leveraging them in their recruitment and retention practices.

Vacancy Rates Influence Recruitment and Retention

Vacancy rates are a key indicator in measuring workforce stability (NCI-IDD, 2024). 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 Caregiver/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 (Hall et al., 2022; Hall et al., 2024). In Tennessee, the overall vacancy rate for Caregivers/DPSs in 2024 was 12% (see Figure 12), slightly higher than the national average indicative the ongoing need for more workers. Of equal importance is the vacancy rate for FLSs in Tennessee which was 7% in 2024 (see Figure 16).

Cost of Turnover

Staff turnover is very costly for organizations. A typical rule of thumb for estimating costs related to turnover is that costs related to exiting an employee and replacing that position are about 25% of the annual salary of the position (Anderson-Hoyt et al., 2010). Organizations in this study reported a total of 10,806 Caregivers/DSPs employed in 2024. Using the 25% of the Caregiver/DSP annual salary rule of thumb for cost of turnover and the average overall Caregiver/DSP wage of $15.79 per hour (Figure 8), turnover costs for each Caregiver/DSP who leaves their position may be $8,210.80. At the rate of $8,210.80 per Caregiver/DSP, a 48% Caregiver/DSP annual turnover rate in the state of Tennessee results in an estimated $42,588,433 in costs related to Caregiver/DSP turnover. Eliminating even half of these costs could result in an annual $1,971 bonus per Caregiver/DSP for the 10,806 Caregivers/DSPs reported.

Access to Support from Frontline Supervisors

A common reason Caregivers/DSPs leave their positions is a lack of or poor quality of support from frontline supervisors (Hewitt et al., 2019). FLSs are an imperative source of Caregiver/DSP support and training on the job. Competent FLSs can improve the retention of Caregivers/DSPs. Without sufficient support, especially for those working in more individualized settings, Caregivers/DSPs may feel less equipped to do their work and more prone to seek employment elsewhere. Turnover and vacancy rates among FLSs also contribute to instability of the Caregiver/DSP workforce. One-quarter (25%) of FLSs left their positions in 2024, with 23% of those frontline supervisors leaving with 0-6 months of hire (Figure 15). There was a 7% vacancy rate in FLSs across participating organizations (Figure 16).

Exploring the reasons why FLSs leave their position could provide valuable insight to provide mechanisms for retention. Another option to consider is whether the National Frontline Supervisor Core Competencies align with current training for FLSs in Tennessee. Competency-based curriculum focusing 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). The NADSP E-Badge Academy implementation in Tennessee began in 2024. Continuing to offer NADSP E-Badge Academy to providers is a workforce strategy to support and ensure competence for supervisors. Improving training and support of FLSs can result in better engagement, communication, and recognition of Caregivers/DSPs in addition to decreasing Caregiver/DSP turnover.

Low Wages & Wage Compression

Organizations reported starting and average wages paid to Caregivers/DSPs. Across reporting organizations, the average starting hourly Caregiver/DSP wages were $15.10 per hour. The average Caregiver/DSP wages were $15.79 per hour. While wages have consistently increased in Tennessee, they are still low. The average starting and average hourly wages for DSPs nationwide in 2023 were $16.49 and $17.34, respectively (NCI-IDD, 2024). Studies have demonstrated the relation between wages and DSP turnover rates. Organizations that pay higher wages have lower turnover rates (Pettingell et al., 2022; Houseworth et al., 2020).

Over the last few years, Tennessee has enacted legislated pay rates that increased pay rates for entry level positions. In 2024, the starting and average wages for Caregivers/DSPs only differ by $0.69, indicating an issue of wage compression, meaning those with high tenure and experience are paid close to the same rate as someone new to the field. This can cause longer tenured employees to leave the field. The challenge of increasing rates for tenured staff is receiving attention through legislative and social recognition. Statewide, only half (49%) of organizations offer a wage increase for longevity, 46% offer a wage increase tied to performance, and 22% offer a wage increase for continued training. With sufficient funding, this strategy could be modified with a larger wage increase or the wage increase occurring earlier in the Caregivers/DSPs tenure. Using a credentialing model or career ladder to provide incentives for professional development may influence the trajectory of this continued low wage trend and issue of wage compression.

Cost of Overtime

An important workforce issue for organizations is the level of Caregiver/DSP overtime hours and money paid out for overtime. Statewide, the average number of overtime hours that organizations paid out to full-time Caregivers/DSPs in 2024 was 28,733 (range 0 to 1,032,413), and the total number of overtime hours paid out was 2,959,455 (Figure 10). The average cost of full-time Caregiver/DSP overtime in 2024 was $228,787 (range $0 to $7,830,853), and the total cost of full-time Caregiver/DSP overtime was $23,107,507 (Figure 11). Filling vacancies reduces overtime costs which allows providers the opportunity to reallocate cost savings to other areas of need to address workforce recruitment and retention such as increasing wages, enhancing benefits or providing professional development. When providers can pay more to Caregivers/DSPs, burnout and turnover may be reduced and relationships with people supported remain stable.

Limited Benefits

Access to benefits is another important strategy used to retain Caregivers/DSPs. Access to health insurance and paid time off are additional measures that can increase Caregiver/DSP tenure, especially as the job market is increasingly competitive. Just over half (54%) of organizations reported offering health (medical) 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. Perhaps the cost of health insurance is simply too great for Caregivers/DSPs to afford the benefit alongside other costs of living. Given this possibility, more affordable options need to be explored. In addition, only one-third (25%-36%) of organizations offered pooled paid time off, sick leave, paid vacation, or paid personal time off (Table 5) in 2024. 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. Direct support is demanding, and a profession with one of the highest rates in the nation (Bureau of Labor Statistics, 2020). Examining and improving paid leave policies is another strategy to support this workforce.

Recommendations

Survey Administration & Data Collection Efforts Support Workforce Development

Monitoring direct support key workforce metric trends is essential. It is important for the MCOs and TennCare to continue their efforts to ensure adequate resources are available for survey development and implementation, data collection, and ongoing analyses. Related to that is the importance of understanding which providers are in the sample of providers and how representative they are of the larger group which impacts the quality of the data.

Sample

Understanding the sample of providers is important. The Tennessee sample includes providers supporting the ECF CHOICES population from the intellectual and developmental disabilities sector, providers supporting the CHOICES (Non-ECF CHOICES) population from the aging and disability sector, and providers supporting both population sectors. A representative sample is imperative for interpreting the results and connecting them to practical solutions. A stable sample is needed to reliably track data trends for key workforce metrics over time. In year 7, the MCOs continued their efforts to establish a representative and stable sample. They reached out to each of the organizations to verify contact information and determine eligibility based on criteria that were established in 2024. This process is important and using it annually will help to further guarantee that data are reflective of the populations of interest and solutions are applicable to the services they provide.

Data Collection

Data collection is an extremely important part of the annual survey process. While it is time-consuming, it is crucial to have sufficient data that is of high quality to implement solutions for stabilizing the workforce. MCO data collection teams have worked to establish accurate contact information for each organization prior to the survey launch recognizing numerous communications may be necessary before the correct contact person is determined. They have a system of regular and intentional communication with the survey contact(s) during the data collection period which fosters relationships and guarantees organizations feel supported in their data reporting efforts. One of the key factors influencing organizations participation and provision of quality data is a strong relationship with the MCO data collection teams. It is important to continue to develop and grow these relationships, so organizations understand the importance of their data with respect to their own workforce metrics as well as having their voice heard in the aggregated results.

While relationships are directly related to successful data collection, there are data specific issues to consider as well. Multiple sources of data can provide a more thorough understanding of the Caregiver/DSP workforce. The quantitative data collected from the annual survey provides information on key workforce metrics (e.g., wages, benefits, vacancies, turnover, etc.); however, it does not provide more granular exploration of what may be driving these metrics. Using qualitative methods of data collection (interviews, focus groups, etc.) and gathering data from other sources (e.g., Caregivers/DSPs, Frontline Supervisors, and other employee groups) can help organizations understand factors related to their key metrics and what strategies may be effective options for them to best support and address workforce stability.

Lastly, evaluating and monitoring workforce data trends over time is imperative to understanding whether workforce solutions that have been implemented are successful or where they need to be modified or changed. To do this effectively, creating a system to track workforce strategies and solutions that organizations have implemented to address recruitment and retention issues (e.g., time spent using technical assistance, training initiatives, etc.) is recommended. This information provides context for understanding and explaining trends and changes. MCO data teams added a question to the annual survey in year 7 asking if the organization was involved with or working on Tennessee workforce development initiatives with the MCO workforce development teams and if so, what activities did that include. This is a good start to understanding involvement more broadly, but other systems should also be considered to explore workforce development involvement more granularly.

Survey

MCOs have continually listened to feedback provided by organizations around the annual survey and in response have adjusted it to improve the survey experience. Efforts have been made to provide clearer instructions and definitions; however, as organizations report issues, continual refinement is needed as misunderstanding introduces the possibility of inaccurate data.

Given there are two workforce sectors, IDD and aging/disability, some consideration should be given to understanding them separately. While there are some similarities between the two, Caregivers/DSPs, while providing some overlapping services and supports, differ in their skills, responsibilities, and scope of work. In addition, the needs of the individuals supported are different, although overlapping at times. When the workforce sectors are combined, the voice of each group is lost, interpretation of results is less clear, and recommendations for strategies to address workforce sector needs cannot be parsed out. Data that provide national and state benchmarks for workforce metrics are collected separately via the National Core Indicators IDD and AD State of the Workforce Surveys. Initial data from these reports depict differences between the workforce sectors in key workforce metrics. That said, while there is precedent for collecting data from each workforce sector, that decision needs to be balanced with the burden of data requested from organizations.

Ongoing Support for Provider Organizations Encourages Workforce Development

Workforce recruitment and retention are persistent challenges and as the demand increases for Caregivers/DSPs and the number of candidates decreases, it remains important for provider organizations to find, hire, and keep qualified and committed candidates so they can provide quality care. For this to be done effectively, there is a continued need for building MCOs’ capacity for providing organizations with targeted, ongoing training and technical assistance.

In the past, Tennessee organizations have participated in training offered in multiple ways including individualized consultation with workforce consultants and MCO coaches, participating in webinars, attending 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. Organizations may become more motivated to participate in developing and improving their workforce when their efforts toward the implementation of evidence-based recruitment and retention strategies or demonstration of specific quality of life outcomes are rewarded with financial incentives.

For the first time, in 2024, organizations were asked to indicate if they were involved in Tennessee workforce development initiatives with the MCO workforce development teams, and if so which ones. Tracking this data moving forward can help shed light on the collaborative efforts regarding workforce development, between MCOs and provider organizations in Tennessee and serve as a valuable measure in understanding the development of the workforce statewide.

Evidence Based Recruitment Marketing Ensures the Best Candidates are Found

While Caregivers/DSPs vacancy rates in Tennessee are in line with national averages this year, they remain high. Finding ways to attract a new and diverse workforce into the field and recruit quality Caregivers/DSPs can help reduce the number of positions that are vacant within an organization, and reduce overtime costs, which are high.

Developing community partnerships and utilizing other community outreach efforts like public service announcements (PSAs) and targeted marketing flyers can elevate and shed light on the role of the DSP. Marketing benefits that align with the employment types an organization aims to recruit will increase the likelihood applicants are a good match. Encouraging Caregivers/DSPs to share positive reasons about why they stay or utilizing referral bonuses can help incentive current staff to solicit new and diverse workforce members to the team.

The TN DSP Workforce Toolkit, developed by TennCare, in partnership with the University of Minnesota, offers evidenced based recruitment and marketing tools and strategies for use by organizations, such as public service announcements (PSAs) and recruitment flyers. Individual support from the Tennessee Workforce Development Teams regarding the use of these tools and strategies is recommended as it allows organizations to implement these tools and strategies in ways that align with their own organization mission and evaluate their effectiveness with improving vacancy and retention organization wide.

Selecting & Hiring Staff that are a Good Fit Improves Early Retention

Organizations in Tennessee continue to experience difficulties with workforce staff leaving soon after hire. Effective selection practices can ensure that only the most qualified and committed candidates, or those who are good fit, are hired for the position. Being transparent about the job by using a realistic job preview (RJP) ensures that applicants fully understand the requirements before accepting an offer and using competencies to interview applicants, such as with a competency based structured behavioral interview (SBI) process, ensure that only the candidates with the knowledge, skills, abilities, and attitudes that align with the job and the organization are selected and hired. New hires, who have a realistic understanding of the job and have been systematically selected to join the team using RJPs and SBIs, are more likely to stay.

Additionally, ensuring those new hires receive an effective and supportive orientation and onboarding increases their chances of having a strong start and a good first impression of the organization. Orientation and onboarding practices that go beyond what is mandated or required, that are welcoming and supportive and emphasize the importance of feeling connected to the organization quickly, help ensure that new hires thrive, have a good experience early on, and stay long term. The Tennessee Workforce Development Teams have provided opportunities for organizations to learn about and use retention tools. Additional follow-up with organizations to understand which tools they are implementing and how they are being used to ensure alignment with their specific workforce-related needs is recommended as this is another mechanism for organizations to implement related to vacancy and retention.

Competency-Based Workforce Models & Employee Engagement Improves Retention

Turnover is not only occurring at high rates within a Caregivers/DSPs first year, but for those with longer tenure as well. Investing in the current workforce is important. An organization that utilizes best practices in retention, engagement, and the professional development of the workforce they have is more likely to maintain a stable, committed, and competent workforce.

Competency-based workforce models help elevate workforce roles to align with the level of complexity and responsibility that entail. Competencies are knowledge, skills, and attitudes needed to perform a job. DSP and FLS competencies can serve as a universal language to unify and elevate the idea of what it takes to do the job and can be used from start to finish in an organization. Competency base job descriptions ensure applicants understand the skills they are expected to have when applying; competency based training and professional development programs ensures that staff develop a consistent set of skills that align with not only the job description but what is expected at the organization, and competency-based skills assessments and performance evaluations ensure that staff demonstrate these skills that they are trained on.

The use of career pathways and credentialing programs empowers direct support staff to grow professionally and see their work as a career versus a job. Recognizing staff with wage increases for increased skills (in addition to things like tenure and performance) can increase employee engagement and improve retention of workforce staff across employee tenure. Benefit utilization is low for Caregivers/DSPs in Tennessee. Continuing to track benefits utilization and using benefits satisfaction surveys can improve retention of current staff by ensuring staff have what they want and need to do their job. Finally, strong relationships between FLSs and the DSPs they oversee, including effective supervision, coaching, and mentoring, ensures that direct support staff are feeling supported and engaged within an organization. Quality support for FLSs is needed for this to occur also. The Tennessee Workforce Development Teams have provided opportunities for organizations to engage in related to career pathways and credentialing programs and training programs for DSPs and FLSs. Continuing to provide support to organizations for staff to participate in these opportunities and understanding the utilization of these opportunities by DSPs and FLSs within organizations is important to encourage and invest in direct support staff and thereby improve quality of care.

Conclusion

There continues to be improvements made in Tennessee efforts to address direct support workforce stability. The systems level approach, dedicated employees within the provider organizations, and the collaboration across key collaborators continue to be important to the successes experienced to date.

The Tennessee LTSS Workforce Quality Improvement Survey is one part of the comprehensive efforts to learn about and support the direct support workforce in Tennessee. The findings inform data-driven solutions to support organizations to recruit, hire, and retain Caregivers/DSPs. Many trends in key workforce metrics continue to be encouraging. While there are fluctuations in the retention measures, they are to be expected and good to be aware of. This data, when used to inform training and consultation on workforce solutions, is intended to help address the workforce crisis when implemented with fidelity over time. Organizations that participate are well-positioned to see a more stable, competent, and committed workforce over time.

The need to continue the momentum and monitor these trends still exists. Ultimately, as this work continues, the hope is that other key workforce indicators continue to improve in all services and supports for people with disabilities, including IDD, and older adults irrespective the types of services they receive. These efforts will result in improved services for people with disabilities, including IDD, and older adults being supported in the state.

References

• Anderson-Hoyt, J., McGee-Trenhaile, M., & Gortmaker, V. (2010). Direct Support Professional Wage Study: 2009. Alexandria, VA: ANCOR.
• Bogenschutz, M. D., Hewitt, A., Nord, D., & Hepperlen, R. (2014). Direct Support Workforce Supporting Individuals With IDD: Current Wages, Benefits, and Stability. IDD, 52(5), 317–329. https://doi.org/10.1352/1934-9556-52.5.317
• Bureau of Labor Statistics. (2020). Employer-Reported Workplace Injuries and Illnesses – 2019 (USDL-20-2030). (p. 9). U.S. Department of Labor. https://www.bls.gov/news.release/pdf/osh.pdf
• Campbell, S., Del Rio Drake, A., Espinoza, R., & Scales, K. (2021). Caring for the Future: The Power and Potential of America’s Direct Care Workforce. PHI. https://www.phinational.org/resource/caring-for-the-future-the-power-and-potential-of-americas-direct-care-workforce/
• DirectCourse. (2021). College of Direct Support/College of Frontline Supervision and Management. https://directcourseonline.com/
• Friedman, C. (2018). Direct support professionals and quality of life of people with intellectual and developmental disabilities. Intellectual and Developmental Disabilities, 56(4), 234–250. https://doi.org/10.1352/1934-9556-56.5.234
• Friedman, C. (2021a). The impact of direct support professional turnover on the health and safety of people with intellectual and developmental disabilities. Inclusion, 9(1), 63–73. https://doi.org/10.1352/2326-6988-9.1.63
• Friedman, C. (2021b). The impact of ongoing staff development on the health and safety of people with intellectual and developmental disabilities. Journal of Developmental and Physical Disabilities, 33(2), 181–196. https://doi.org/10.1007/s10882-020-09743-z
• Hall, S. A., Anderson, L. L., Pettingell, S. L., Zhang, A., Bershadsky, J., Hewitt, A., & Smith, J. (2022). Direct support professional and frontline supervisor perspectives on work-life in a pandemic. Inclusion, 10(4), 314–326. https://doi.org/10.1352/2326-6988-10.4.314
• Hall, S., Lahti Anderson, L., & Pettingell, S. L. (2024). The self-perpetuating turnover cycle: Frontline supervisors and direct support professionals reflect on its causes and impacts. Inclusion, 12(3), 172–185. DOI: 10.1352/2326-6988-12.3.172
• Hewitt, A., Pettingell, S., Bershadsky, J., Smith, J., Kleist, B., Sanders, M., Zhang, A., Dean, K., & Kramme, J. (2021). Direct Support Workforce and COVID-19 Survey: Providing Support During the COVID-19 Pandemic: Twelve Month Follow Up. Institute on Community Integration, University of Minnesota. https://ici.umn.edu/covid19-survey
• Hewitt, A., Pettingell, S., & Kramme, J. (2019). Minnesota Direct Support Worker Survey 2019: Final report. Institute on Community Integration, Research and Training Center on Community Living. https://ici.umn.edu/products/view/kfpN9PofQGWQNrV3FwsfeA
• Houseworth, J., Pettingell, S., Kramme, J., Tichá, R., & Hewitt, A. (2020). Predictors of annual and early separations among direct support professionals: National Core Indicators Staff Stability Survey. Intellectual and Developmental Disabilities, 58(3), 192–207.
• Larson, S. A., Tolbize, M. S. A., Kim, O., & York, B. (2016). Direct Support Professional Turnover Costs in Small Group Homes: A Case Study. Minneapolis: University of Minnesota, Research and Training Center on Community Living.
• Moss, K. (2022). Wage Increases for Frontline HCBS Workers in Employment and Community First CHOICES. Division of TennCare. https://www.tn.gov/content/dam/tn/tenncare/documents/July12022ECFRateMemoFINAL.pdf
• National Core Indicators Intellectual and Developmental Disabilities. (2024). National Core Indicators Intellectual and Developmental Disabilities 2023 State of the Workforce Survey Report. https://idd.nationalcoreindicators.org/survey-reports-insights/
• Pettingell, S. L., Houseworth, J., Tichá, R., Kramme, J. E. D., & Hewitt, A. S. (2022). Incentives, wages, and retention among direct support professionals: National Core Indicators Staff Stability Survey. Intellectual and Developmental Disabilities, 60(2), 113–127. https://doi.org/10.1352/1934-9556-60.2.113
• PHI. (2021). Direct care workers in the United States: Key facts. PHI Quality Care Through Quality Jobs. https://www.phinational.org/resource/direct-care-workers-in-the-united-states-key-facts-2/
• President’s Committee for People with Intellectual Disabilities [PCPID]. (2024). Report to the President 2024: Advancing independence and community integration for all: Supporting individuals with intellectual disabilities through high-quality home and community-based services. Washington D.C.: Author.
• Sheppard-Jones, K., Kleinert, H., Butler, L., Li, J., Moseley, E., & Adams, C. (2022). Direct support professionals: Stress and resiliency amidst the COVID-19 pandemic. Intellectual and Developmental Disabilities, 60(3), 246–255. https://doi.org/10.1352/1934-9556-60.3.246
• Spreat, S. (2021). Direct Support Professional Vacancies in the IDD Field: A Study Over Time. International Journal of Economics, Business, and Management Research, 5(5), 274–282.