Tennessee LTSS Workforce Quality Improvement Survey 2023

The Institute on Community Integration (ICI) at the University of Minnesota worked in collaboration with Wellpoint (formerly Amerigroup), UnitedHealthcare, BlueCare TN, and TennCare to develop and administer the Quality Improvement in Long Term Services and Supports Workforce Initiative 2023 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 began with a collaboration between TennCare, Tennessee Community Organizations (TNCO) and ICI to address workforce challenges for direct support professionals (DSPs) in Tennessee. This annual survey continues to be a key component of a comprehensive workforce strategy in the Quality Improvement in Long-Term Services and Supports (QuILTSS) Initiative. As part of this comprehensive effort, the first three years of the survey focused on gathering data on DSPs working with people with intellectual and developmental disabilities. Those data are informing ongoing discussions and planning about wages, benefits, and ways to recruit and retain good employees and enhance access to home and community-based services (HCBS) for people with intellectual and developmental disabilities in Tennessee. Also, during the first three years of this initiative, participating organizations received a data summary about the DSP workforce in their organization and had the opportunity to take advantage of training and technical assistance from ICI workforce consultants and Tennessee workforce coaches to identify and address at least one key challenge that their organization faced to improve their direct support workforce turnover and retention rates. Following the first three years, Tennessee workforce coaches continued consultation with organizations and have expanded avenues of support for provider organizations. In years 4, 5 and 6, the survey was expanded to include Caregivers for older adults and people with disabilities 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: Barbara Kleist, Sandra Pettingell, Heather Barcikowski, Quinn Oteman, Megan Sanders, and Yi-Chen Wu.

Report layout and design by Sarah Curtner and Shawn Lawler.

Suggested Citation:

• Pettingell, S., Barcikowski, H., Bershadsky, J., Kleist, B., Oteman, Q., Sanders, M., & Wu, Y. (2024). Tennessee LTSS Workforce Quality Improvement Survey 2023 Year Six Report. Minneapolis: University of Minnesota, Institute on Community Integration.

Background

Caregivers/Direct support professionals (DSPs) provide vital supports and services for older adults and people with disabilities so that they can live, work, and be fully engaged in their communities. The direct support workforce continues to be among occupations with the highest growth rate in the United States. It has grown 48% in the last decade from 3.5 million workers in 2014 to over 5 million workers in 2023. This expansion is anticipated to continue to include another 861,000 workers by 2032. Both due to this expansion of the workforce and job separation of those currently in the workforce, it is expected that there will be 8.9 million direct care job openings between 2022 and 2032 (PHI, 2024). While demand for workers remains high, it surpasses the number of new workers desiring to enter the profession, creating perpetual staff shortages and high vacancies. It is challenging for organizations to keep workers after they are hired due to low wages, access to affordable benefits, and competition for workers with other industries. The direct support workforce shortage is an enduring crisis across the U.S. and is particularly problematic within Home and Community Based Services (HCBS) for persons with intellectual and developmental disabilities (IDD; Scales, 2020).

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 a stable and sufficient 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 experience more injuries and instances of abuse and neglect. The safety and health of people with disabilities improves when DSPs have longer tenure (Friedman, 2021a). It is important to have timely and effective solutions to the Caregiver/DSP workforce shortage that are available, adequately funded, and evaluated so that people with disabilities and older adults experiences in community living are fulfilling (President’s Committee for People with Intellectual Disabilities, PCPID, 2024).

There is a significant need for collection, analysis, and use of workforce data 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, people with disabilities, and people with IDD. Workforce strategies, such as providing ongoing staff development and recruiting qualified people into the field, can meaningfully 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 DSPs (PCPID, 2024).

TennCare is Tennessee’s state Medicaid program that administers services to over 1.4 million people. As part of a statewide workforce initiative, TennCare sought a method to regularly collect, analyze, and use provider-, program-, and state-level comprehensive workforce data for its Managed Long-Term Supports and Services (MLTSS) that support HCBS programs for people with disabilities. This effort was initiated in 2019 and is connected to the Quality Improvement in Long-Term Services and Supports (QuILTSS) Initiative. In 2021 the implementation of this annual workforce survey was transferred to the three Tennessee Managed Care Organizations. 2024 was the sixth year of the implementation of the Tennessee LTSS Workforce Quality Improvement Survey (formerly the QulLTSS Initiative Survey), which asked disability and aging provider organizations that deliver primarily Employment and Community First CHOICES and CHOICES (Non-ECF CHOICES) in Tennessee and employ Caregivers/DSPs to report their workforce data from the previous calendar year. This report presents a summary of data from 114 provider organizations that completed the 2023 survey regarding their workforce in those programs.

Year Six Methodology

Year Six Survey Development & Administration

The year six survey (using calendar year 2023 data) was updated after the year 5 cycle in collaboration with TennCare and the Managed Care Organization (MCO) workforce leads from Wellpoint, BlueCare TN, and UnitedHealthcare. The finalized survey was converted into an online Qualtrics survey. Internal and external pilot tests were conducted to ensure functionality of the online survey. The year six survey launched on June 3, 2024. A webinar was delivered on June 5, 2024, for all organizations invited to complete the year six survey. The purpose of the webinar was to introduce the survey, clarify items that were more difficult for participants in previous years, and answer questions. The webinar was recorded and made available on demand for organizations who were unable to attend and as a resource for all organizations to reference as they were completing the survey. Data collection closed on August 16, 2024. Follow-up was conducted with all organizations that provided data that was inconsistent and/or had other issues that needed clarification during data cleaning phase. Clean-up and analyses were conducted from August 19, 2024, to August 30, 2024.

Recruitment, Sample, and Response Rate

The Wellpoint, BlueCare TN, and UnitedHealthcare MCOs provided a list of 391 organizations that employed Caregivers/DSPs and participated in ECF CHOICES/1115 Waiver and CHOICES (Non-ECF CHOICES)/1115 Waiver in 2023. MCOs verified each organization’s address, primary contact person, and that person’s contact information. ICI drafted an invitation letter to the organizations in the sample, and MCOs reviewed and distributed the letter. The letter introduced the survey to the organizations by communicating its purpose, how the data would be used, how it would be helpful to them, and encouraged participation.

As a result of recommendations from year 5, the survey included new qualification questions at the beginning to allow for focusing the sample to only those organizations that were qualified to participate. Qualification criteria included being a Home and Community Based Services (HCBS) provider; providing at least one of ECF CHOICES/1115 Waiver, DIDD Waiver/1915c Waiver, Vocational Rehabilitation, or CHOICES (Non-ECF CHOICES)/1115 Waiver services in 2023; and having Caregivers/DSPs on payroll December 31, 2023. In addition, providers who only employed contract or 1099 Caregivers/DSPs, used only a Family Model Professional (FMP) or Shared Living Approach (SLA) service delivery method, or only provided nursing home or hospice care were excluded. Of the 391 organizations who received the survey invitation email, those who initially indicated that they were not eligible received follow-up communications to verify their ineligibility. For some providers, after a conversation, they realized they did qualify. This required them to complete a paper/pencil version of the survey as the Qualtrics link expired after the initial submission. This provided some challenges for providers to submit their data. For some providers, they never responded to clarify whether they were eligible or not. For those who did not confirm, they were left as ineligible per their original indication. There were 54 (14%) who either verified they did not meet the qualification criteria or who never responded to follow-up. This left a sample of 337 eligible organizations.

Of the 337 eligible participants in year six, 114 (34%) submitted a year six survey, and 39 (12%) started the survey but did not complete it. Additionally, 170 (50%) did not open the survey, and 14 (4%) declined to participate. Of the 114 submitted surveys, 28 organizations (26%) also participated in year one, 38 organizations (33%) participated in year two, 37 (32%) participated in year three, 63 (55%) participated in year 4, 83 (73%) participated in year 5, and 14 organizations (12%) were new participants.

The final analytic sample for year 6 was 114 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 114 organizations, 37 (33%) provided their highest percentage of service in the East counties, 41 (36%) provided their highest percentage of service in the Middle counties, and 36 (31%) provided their highest percentage of service in the West counties. There were 2 organizations that did not provide information on the percentage of services offered within each region and 3 organizations that provided equal percentage of services in multiple regions, meaning there was no highest region. In those instances, home office location was assigned as their region of services.

114 organizations completed the year six survey, reporting on calendar year 2023. In previous cycles, 154 organizations completed the year five survey reporting on calendar year 2022, 131 organizations completed the year four survey reporting on calendar year 2021, 63 organizations completed the year three survey reporting on calendar year 2020, 75 organizations completed the year two survey reporting on calendar year 2019, and 47 organizations completed the year one survey reporting on calendar year 2018.

Year Six Results

This project includes organizations providing workforce data on the services and supports they provide in the IDD and aging and disabilities sectors. Years one, two and three focused solely on the sector of the workforce providing services to individuals with IDD. Beginning in year four, providers in the aging and disabilities sector were introduced to the project and added to the sample. For the purposes of this report, Caregivers and DSPs were combined into a single group to represent the direct support workforce. This means caution needs to be taken when examining trends over time recognizing the samples are different across time.

This report provides an overview of state level survey data. State and regional data profiles are available in Appendix A. Survey items were analyzed by region when there was a large enough sample size. Regional breakdowns were based on where the organization’s highest percentage of services were located. Unless otherwise specified, responses to survey questions reflect calendar year 2023. It is important to note that while 114 organizations participated in the survey, not all organizations answered all questions. The number of responding organizations is indicated where appropriate in each section.

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: 33%
• Tennessee Middle: 36%
• Tennessee West: 31%

Figure 1 indicates the percentage of services that 114 organizations provided in the East, Middle, and West regions of Tennessee. In the state, 33% of organizations provided services in the East region, 36% provided services in the Middle region, and 31% provided services in the West region.

When looking at administrative office headquarters, 30% (34 organizations) had their administrative office in the East region, 40% (46 organizations) were in the Middle region, and 30% (34 organizations) were located in the West region. Most organizations provided services in one region (84%), though 9% provided services in two regions and 7% provided services in three regions.

Service Areas

As seen in Figure 2, of the 111 reporting organizations, 72% provided CHOICES (Non-ECF CHOICES)/1115 Waiver, 55% ECF CHOICES/1115 Waiver, 50% DIDD Waiver/1915c Waiver, and 18% Vocational Rehabilitation. Additionally, 48% of organizations provided 1 service, 23% two services, 16% three services, and 13% all four services. The average number of services provided was 2. The number of services provided ranged from 1 to 4.

• CHOICES (Non-ECF CHOICES)/1115 Waiver (80): 72%
• ECF CHOICES/1115 Waiver (61): 55%
• DIDD Waiver/1915cWaiver (56): 50%
• Vocational Rehabilitation (20): 18%

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 had been in business delivering services to people with disabilities and/or older adults for 24 years with a range of 1 to 100 years.

Supports Provided

Figure 3 summarizes the supports provided by the organizations to people with disabilities and/or older adults across the state. Statewide, 41% of organizations provided residential supports, 83% in-home supports, and 48% non-residential supports.

• residential supports: 41%
• in-home supports: 83%
• non-residential supports: 48%

In the East region, 53% of organizations provided residential supports, 78% in-home supports, and 58% non-residential supports. In the Middle region, 39% of organizations provided residential supports, 88% in-home supports, and 41% non-residential supports. In the West region, 31% of organizations provided residential supports, 81% in-home supports, and 44% non-residential supports.

People Served and Organization Staffing

• DIDD = Department of Intellectual and Developmental Disability
• ECF CHOICES = Employment and Community First CHOICES
• CHOICES (Non-ECF CHOICES) = Non-Employment and Community First CHOICES
• VR = Vocational Rehabilitation

Organizations provided services across DIDD Waiver/1915c Waiver, ECF CHOICES/1115 Waiver, CHOICES (Non-ECF CHOICES)/1115 Waiver, and VR services. Across the state, the average number of people for whom organizations provided DIDD Waiver/1915c Waiver, ECF CHOICES/1115 Waiver, CHOICES (Non-ECF CHOICES)/1115 Waiver, and/or VR services was 103 people (range 1 to 1,261). The average number of people served in the East region was 104 (range 3 to 1,261) across 34 organizations. The average number of people served in the Middle region was 94 (range 1 to 1,092) across 40 organizations. The average number of people served in the West region was 111 (range 3 to 789) across 32 organizations.

As seen in Figure 4, the organizations who responded to the survey supported a total of 10,876 people who are aging, have physical disabilities or those with I/DD and employed a total of 10,753 Caregiver/DSPs and 1,484 FLSs. In the East region, there were 3,554 people served by 34 organizations with supports from 3,508 Caregivers/DSPs and 370 FLSs. In the Middle region, there were 3,761 people served by 40 organizations with supports from 2,831 Caregivers/DSPs and 199 FLSs. For the West region, there were 3,561 people served by 32 organizations with supports from 4,414 Caregivers/DSPs and 915 FLSs.

• people served: 10,876
• caregivers/DSPs: 10,753
• FLSs: 1,484

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 89 organizations who reported, the average number of hours per week a Caregiver/DSP needed to work to be considered full-time was 35 with a range of 1-80 hours.

Fifty-three percent of Caregivers/DSPs were full-time, 42% were part-time, and 5% were on-call/temporary or relief staff. Forty-one 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: 42%
• full-time: 53%

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

• In the East region, 56% were full-time, 41% were part-time, and 3% were on-call/temporary or relief staff. Forty percent of the Caregivers/DSPs worked across more than one service type.
• In the Middle region, 61% were full-time, 34% were part-time, and 5% were on-call/temporary or relief staff. Forty-two percent of the Caregivers/DSPs worked across more than one service type.
• In the West region, 40% were full-time, 53% were part-time, and 7% were on-call/temporary or relief staff. Forty percent of the Caregivers/DSPs worked across more than one service type.

Caregivers/Direct Support Professionals

Caregiver/Direct Support Professional Wages

Enhanced HCBS FMAP Funds are dollars being used within Tennessee’s Home and Community Based Services (HCBS) Programs—CHOICES (Non-ECF CHOICES)/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, 2023. 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 $14.55, the overall average wage for all Caregivers/DSPs was $15.01, and the average highest wage for all Caregivers/DSPs was $16.69.

Organizations were asked to report whether Caregivers/DSPs who work in different service types are paid the same wage for each service. Overall, 12% of organizations pay Caregivers/DSPs different wages for different service types. In the East region 8% of organizations pay Caregivers/DSPs different wages for each service type. In the Middle and West regions, the percentages are higher, with 12% and 18%, respectively, of organizations paying Caregivers/DSPs different wages for each service type.

• starting: $14.55
• highest: $16.69
• average: $15.01

Caregiver/Direct Support Professional Starting Wages

The average starting wage for part-time Caregivers/DSPs was $14.60 (range $11.00 to $21.44). The average starting wage for full-time Caregivers/DSPs was $14.76 (range $10.00 to $21.86). The average starting wage for Caregivers/DSPs overall was $14.55 (range $10.00 to $21.86). These wages are depicted in Figure 7.

Part-time

• State (67): $ 14.60
• West (21): $ 14.19
• Middle (24): $ 14.60
• East (22): $ 14.70

Full-time

• State (67): $ 14.76
• West (18): $ 14.69
• Middle (26): $ 14.74
• East (23): $ 14.82

Overall

• State (112): $ 14.55
• West (34): $ 14.46
• Middle (41): $ 14.62
• East (37): $ 14.56

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 $14.70 (range $11.00 to $17.25). The average starting wage for full-time Caregivers/DSPs was $14.82 (range $11.00 to $17.70). The average starting wage for all Caregivers/DSPs was $14.56 (range $10.00 to $17.70).
• In the Middle, the average starting wage for part-time Caregivers/DSPs was $14.86 (range $12.00 to $18.00). The average starting wage for full-time Caregivers/DSPs was $14.74 (range $11.00 to $17.00). The average starting wage for all Caregivers/DSPs was $14.62 (range $12.00 to $17.00).
• In the West, the average starting wage for part-time Caregivers/DSPs was $14.19 (range $11.00 to $21.44). The average starting wage for full-time Caregivers/DSPs was $14.69 (range $11.00 to $25.00). The average starting wage for all Caregivers/DSPs was $14.46 (range $11.00 to $21.86).

Average Caregiver/Direct Support Professional Wages

Part-time

• State (67): $ 15.01
• West (21): $ 14.45
• Middle (24): $ 15.23
• East (22): $ 15.33

Full-time

• State (66): $ 15.45
• West (17): $ 15.33
• Middle (26): $ 15.44
• East (23): $ 15.54

Overall

• State (108): $ 15.01
• West (32): $ 14.80
• Middle (39): $ 15.06
• East (37): $ 15.14

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 $15.01 (range $11.00 to $21.44). The average full-time Caregiver/DSP wage was $15.45 (range $12.00 to $25.00). The average overall Caregiver/DSP wage was $15.01 (range $10.00 to $21.86). 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 $15.33 (range $12.50 to $19.00). The average wage for full-time Caregivers/DSPs was $15.54 (range $12.50 to $19.00). The average wage for all Caregivers/DSPs was $15.14 (range $10.00 to $19.00).
• In the Middle, the average wage for part-time Caregivers/DSPs was $15.23 (range $11.00 to $18.00). The average wage for full-time Caregivers/DSPs was $15.44 (range $13.75 to $19.00). The average wage for all Caregivers/DSPs was $15.06 (range $12.00 to $17.50).
• In the West, the average wage for part-time Caregivers/DSPs was $14.45 (range $11.00 to $21.44). The average wage for full-time Caregivers/DSPs was $15.33 (range $12.00 to $25.00). The average wage for all Caregivers/DSPs was $14.80 (range $11.00 to $21.86).

Highest Caregiver/Direct Support Professional Wages

Part-time

• State (65): $ 15.82
• West (20): $ 14.89
• Middle (23): $ 16.13
• East (22): $ 16.34

Full-time

• State (65): $ 16.95
• West (17): $ 16.07
• Middle (25): $ 17.01
• East (23): $ 17.53

Overall

• State (109): $ 16.69
• West (33): $ 15.83
• Middle (28): $ 16.70
• East (37): $ 17.46

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 $15.82 (range $11.00 to $21.50). The average highest wage for full-time Caregivers/DSPs was $16.95 (range $13.00 to $24.48). The average highest wage for all Caregivers/DSPs was $16.69 (range 11.50 to $24.49). 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 $16.34 (range $13.00 to $21.50). The average highest wage for full-time Caregivers/DSPs was $17.53 (range $13.00 to $24.48). The average highest wage for all Caregivers/DSPs was $17.46 (range $11.50 to $24.49).
• In the Middle, the average highest wage for part-time Caregivers/DSPs was $16.13 (range $15.00 to $19.00). The average highest wage for full-time Caregivers/DSPs was $17.01 (range $15.00 to $21.57). The average highest wage for all Caregivers/DSPs was $16.70 (range $15.00 to $19.00).
• In the West, the average highest wage for part-time Caregivers/DSPs was $14.89 (range $11.00 to $18.00). The average highest wage for full-time Caregivers/DSPs was $16.07 (range $14.00 to $21.91). The average highest wage for all Caregivers/DSPs was $15.83 (range $12.89 to $21.91).

Caregiver/Direct Support Professional Wage Increases & Bonuses

Organizations were asked to report on whether they provided wage increases to Caregivers/DSPs during calendar year 2023. 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 2023. Statewide, 45% of organizations provided an hourly wage increase to Caregivers/DSPs for longevity. In the East region, 49% of organizations gave these hourly wage increases, 41% in the Middle region, and 47% in the West region.

Wage increases tied to performance. Organizations were asked whether Caregivers/DSPs earned hourly wage increases tied to performance in 2023. Statewide, 50% of organizations provided an hourly wage increase to Caregivers/DSPs tied to performance. In the East region, 60% of organizations gave these hourly wage increases, 51% in the Middle region, and 38% in the West region.

Cost of living increases. Organizations were asked whether Caregivers/DSPs earned hourly wage increases for cost of living in 2023. Statewide, 36% of organizations provided an hourly wage increase to Caregivers/DSPs for cost of living. In the East region, 46% of organizations gave these hourly wage increases, 37% in the Middle region, and 23% in the West region.

Market-competitive adjustments. Organizations were asked whether Caregivers/DSPs earned hourly wage increases for market-competitive adjustments in 2023. Statewide, 39% of organizations provided an hourly wage increase to Caregivers/DSPs market-competitive adjustments. In the East region, 46% of organizations gave these hourly wage increases, 37% in the Middle region, and 35% 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 2023. Statewide, 15% of organizations provided an hourly wage increase to Caregivers/DSPs for continuing education/competency-based training. In the East region, 19% of organizations gave these hourly wage increases, 12% in the Middle region, and 15% in the West region.

Wage increases implemented to enhance employee retention. Organizations were asked whether Caregivers/DSPs earned hourly wage increases tied to performance in 2023. Statewide, 57% of organizations provided an hourly wage increase to Caregivers/DSPs tied to performance. In the East region, 57% of organizations gave these hourly wage increases, 61% in the Middle region, and 53% in the West region.

Other wage increases. The survey also asked organizations if they offered hourly wage increases to Caregivers/DSPs for other reasons in 2023. Statewide, 27% of the organizations provided wage increases for other reasons. In the East region, 22% of organizations gave these hourly wage increases, 27% in the Middle region, and 32% in the West region. Organizations were asked to specify the other reasons they provided hourly wage increases. The other reasons included:

• Annual/Semi-annual Bonus
• Attendance
• CHOICES requirement
• Good performance.

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, 55% of organizations gave a referral bonus to Caregivers/DSPs across the state. By region, 60% of organizations provided referral bonuses in the East, 56% provided referral bonuses in the Middle, and 50% 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, 30% of organizations provided a hiring bonus to newly hired Caregivers/DSPs. By region, 32% of organizations provided hiring bonuses in the East, 37% 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, 34% of organizations gave a bonus to Caregivers/DSPs for years of service across the state. By region, 35% of organizations provided years of service bonuses in the East, 32% of organizations provided years of service bonuses in the Middle, and 35% of organizations provided years of service bonuses in the West.

Performance recognition bonus. Performance recognition is when employees are rewarded financially for achieving specific goals or benchmarks in addition to their salary as a way to recognize an employee’s efforts that are above expectation and furthers the organization’s mission, vision, and values. Statewide, 42% of organizations gave a performance recognition bonus to Caregivers/DSPs. By region, 43% of organizations provided performance recognition bonuses in the East, 44% of organizations provided performance recognition bonuses in the Middle, and 38% of organizations provided recognition bonuses in the West.

Continuing education/Competency-based training. Statewide, 11% of organizations gave a monetary bonus for continuing education/competency-based training to Caregivers/DSPs. By region, 16% of organizations provided a bonus for continuing education/competency-based training in the East, 12% of organizations provided a bonus for continuing education/competency-based training in the Middle, and 3% of organizations provided a bonus for continuing education/competency-based training in the West.

Other bonuses. Statewide, 18% 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, 27% of organizations provided a bonus for other reasons in the Middle, and 6% 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:

• Highly qualified caregiver program bonus (monthly, quarterly)
• Efficiency premium for clocking in/out & submitting all documentation
• Retention bonus
• Local premiums based on branch and service location
• Agency anniversary
• Holiday bonus
• End of year gift bonus.

Caregiver/Direct Support Professional Work Hours and Overtime

Organizations were asked to respond to questions about the number of hours Caregivers/DSPs worked per week and the number of hours of overtime Caregivers/DSPs were 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 turnover.

Caregiver/Direct Support Professional Work Hours

Organizations reported the average number of hours, including overtime, that Caregivers/DSPs worked per week. The average number of hours Caregivers/DSPs worked per week is summarized in Table 3.

Across reporting organizations in the state, Caregivers/DSPs worked an average of 36 (range 10 to 98) hours per week. For organizations who could differentiate between part-time and full-time employees, part-time Caregivers/DSPs worked an average of 22 (range 5 to 50) hours per week and full-time Caregivers/DSPs worked an average of 41 (range 10 to 90) hours per week.

• In the East region across reporting organizations, Caregivers/DSPs worked an average of 35 (range 10 to 85) hours per week. For organizations who could differentiate between part-time and full-time employees, part-time Caregivers/DSPs worked an average of 23 (range 5 to 50) hours per week and full-time Caregivers/DSPs worked an average of 42 (range 15 to 85) hours per week.
• In the Middle region across reporting organizations, Caregivers/DSPs worked an average of 39 (range 10 to 98) hours per week. For organizations who could differentiate between part-time and full-time employees, part-time Caregivers/DSPs worked an average of 22 (range 9 to 35) hours per week and full-time Caregivers/DSPs worked an average of 40 (range 17 to 57) hours per week.
• In the West region across organizations, Caregivers/DSPs worked an average of 35 (range 10 to 90) hours per week. For organizations who could differentiate between part-time and full-time employees, part-time Caregivers/DSPs worked an average of 22 (range 10 to 40) hours per week and full-time Caregivers/DSPs worked an average of 40 (range 10 to 90) hours per week.

Caregiver/Direct Support Professional Overtime Hours

Organizations reported overtime hours paid to full-time Caregivers/DSPs in 2023. Figure 10 illustrates the number of overtime hours paid to full-time Caregivers/DSPs in 2023. Statewide, the average number of overtime hours that organizations paid out to full-time Caregivers/DSPs in 2023 was 23,369 (range 0 to 579,881). The total number of overtime hours paid out in 2023 by 88 organizations was 2,056,452. In the East region, the average number of overtime hours paid out was 21,754 (range 0 to 123,334) with a total of 717,867 overtime hours paid to full-time Caregivers/DSPs. In the Middle region, the average number of overtime hours paid out was 13,677 (range 0 to 77,171) with a total of 437,661 overtime hours paid to full-time Caregivers/DSPs. In the West region, the average number of overtime hours paid out was 39,171 (range 0 to 579,881) with a total of 900,923 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 increases, 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.

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 2023, 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 2023. 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.

The cost of overtime for the state in 2023 is shown in Figure 11.

Statewide, the average cost of Caregiver/DSP overtime in 2023 was $172,718 (range $0 to $4,154,847) for participating organizations. The total cost of Caregiver/DSP overtime in 2023 from 86 organizations was $14,853,713.

• In the East region, the average cost of Caregiver/DSP overtime in 2023 was $167,713 (range $0 to $799,919). The total cost of Caregiver/DSP overtime in 2023 from 33 organizations was $5,534,533.
• In the Middle region, the average cost of Caregiver/DSP overtime in 2023 was $103,154 (range $0 to $520,000). The total cost of Caregiver/DSP overtime in 2023 from 31 organizations was $3,197,769.
• In the West region, the average cost of Caregiver/DSP overtime in 2023 was $278,246 (range $0 to $4,154,847). The total cost of Caregiver/DSP overtime in 2023 from 22 organizations was $6,121,411.

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, Pettingell, Bershadsky 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 13%. The average vacancy rate for part-time positions was 17%, and the average vacancy rate for full-time positions was 14%.

• 13% overall vacancy rate
  • 17% of part-time positions were vacant
  • 14% of full-time positions were vacant

• In the East region, the average vacancy rate among full-time Caregivers/DSPs was 19%. The average part-time Caregiver/DSP vacancy rate was 21%. The average vacancy rate among all Caregiver/DSP positions was 14%.
• In the Middle region, the average vacancy rate among full-time Caregivers/DSPs was 13%. The average part-time Caregiver/DSP vacancy rate was 19%. 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 10%. The average vacancy rate among part-time Caregiver/DSP position in the West region was 12%. 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

This year, the change was made to use annual turnover ratio as that is what the national benchmarks for the NCI-IDD (NCI-IDD, 2023; https://idd.nationalcoreindicators.org/staff-providers/) and NCI-AD State of the Workforce (https://nci-ad.org/sotw-ad/ ) Surveys use. The formula used to compute 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 at the end of the year. The turnover ratio was defined as:

Statewide, the annual turnover ratio for full-time Caregivers/DSPs in calendar year 2023 was 39%. The turnover ratio among part-time Caregivers/DSPs was 67%. The overall Caregiver/DSP annual turnover ratio was 58% (see Figure 13).

• In the East region, the average turnover ratio among full-time Caregivers/DSPs was 36%. Among part-time Caregivers/DSPs, the average turnover ratio was 67%. The average turnover ratio among all Caregivers/DSPs in the East region was 51%.
• In the Middle region, the average turnover ratio among full-time Caregivers/DSPs was 28%. Among part-time Caregivers/DSPs, the average turnover ratio was 71%. The average turnover ratio for all Caregivers/DSPs in the Middle region was 61%.
• In the West region, the average turnover ratio among full-time Caregivers/DSPs was 57%. The average turnover ratio among part-time Caregivers/DSPs was 64%. The average turnover ratio among all Caregivers/DSPs in the West region was 62%.

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. In a more recent study from New York, Raustiala and colleagues (2015) found that due to recruitment, training and other costs, filling open positions can cost up to $5,000 per new hire. Turnover is also detrimental for people who receive DSP supports because there is little time to develop a supportive relationship with a DSP before a new one is hired (Friedman, 2018). Every Caregiver/DSP who leaves the organization requires an existing employee to cover the vacated shifts while a new Caregiver/DSP is hired and trained. Data were gathered to show the percent of Caregivers/DSPs who left within their first year of employment.

Within 0-6 Months of Hire

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

As seen in Figure 13, statewide, the average Caregiver/DSP separation rate within 0 to 6 months of hire was 55% across all Caregivers/DSPs, 64% for part-time Caregivers/DSPs, and 41% for full-time Caregivers/DSPs.

• In the East region, the average Caregiver/DSP separation rate within 0 to 6 months of hire was 58% across all Caregivers/DSPs, 58% for part-time Caregivers/DSPs, and 35% for full-time Caregivers/DSPs.
• In the Middle region, the average Caregiver/DSP separation rate within 0-6 months of hire was 57% across all Caregivers/DSPs, 73% for part-time Caregivers/DSPs, and 42% for full-time Caregivers/DSPs.
• In the West region, the average Caregiver/DSP separation rate within 0-6 months of hire was 49% across all Caregivers/DSPs, 58% for part-time Caregivers/DSPs, and 50% for full-time Caregivers/DSPs.

Within 6-12 Months of Hire

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

Statewide, the average Caregiver/DSP separation rate within 6 to 12 months of hire was 24% across all Caregivers/DSPs, 18% for part-time Caregivers/DSPs, and 31% for full-time Caregivers/DSPs (see Figure 13).

• In the East region, the average Caregiver/DSP separation rate within 6 to 12 months of hire was 21% across all Caregivers/DSPs, 14% for part-time Caregivers/DSPs, and 25% for full-time Caregivers/DSPs.
• In the Middle region, the average Caregiver/DSP separation rate within 6 to 12 months of hire was 23% across all Caregivers/DSPs, 13% 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 28% across all Caregivers/DSPs, 26% for part-time Caregivers/DSPs, and 37% for full-time Caregivers/DSPs.

• overall turnover: 58%

Of those who left:

• 55% left within 0-6 months of hire
• 24% left within 6-12 months of hire

Reasons Caregivers/Direct Support Professionals Give for Leaving Their Positions

Most of the organizations who participated (71%) 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 the greatest to least percentage of organizations in the state.

Statewide, organizations reported “No call/No show” (76%) as the most common reason for Caregivers/DSPs leaving their position. “Found another job at another company” (65%) was the second most common reason, and “Was terminated/fired” (63%) was the third most common reason for Caregiver/DSP departure. Other reasons included: “Not a good fit for the type of work” (41%), “Pay too low/needed better pay” (36%), “Advanced to a new position within the company in a different service” (19%), “Could not get along with co-workers” (15%), “Having too little or poor quality time with their supervisor” (6%), “Training/support was inadequate” (6%), and “Not recognized for the work they did” (4%). 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-third (30%) 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]
• Family Issues/responsibilities
• Moved/relocated
• Personal reasons
• Policy violations
• Retirement
• School schedule/needs
• Training incomplete or not done.

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. Comparing the 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 whether 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, 38% of the reporting organizations offered pooled paid time off (PTO) to some or all Caregivers/DSPs, 20% offered paid sick leave, 31% offered paid vacation, and 21% offered paid personal time.

• In the East region, 38% of the reporting organizations offered pooled paid time off (PTO) to some or all Caregivers/DSPs, 26% offered paid sick leave, 39% offered paid vacation, and 30% offered paid personal time.
• In the Middle region, 44% of the reporting organizations offered pooled paid time off (PTO) to some or all Caregivers/DSPs, 16% offered paid sick leave, 26% offered paid vacation, and 19% offered paid personal time.
• In the West region, 31% of the reporting organizations offered pooled paid time off (PTO) to some or all Caregivers/DSPs, 19% offered paid sick leave, 29% offered paid vacation, and 15% offered paid personal time.

Health Insurance

Organizations reported if they offered health (medical) insurance to some or all of their Caregivers/DSPs. For those that reported this provision, they were also asked to report the minimum number of hours to be eligible for health (medical) insurance and the percentage of those eligible who enrolled.

Statewide as seen in Table 6, 64% of the 114 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, 29% (range 0% to 100%) of Caregivers/DSPs were enrolled in health insurance through their organization.

• In the East region, 62% of the 37 reporting organizations offered health insurance to some or all Caregivers/DSPs. On average, 47% (range 0% to 100%) of Caregivers/DSPs were enrolled in health insurance through their organization.
• In the Middle region, 66% of the 41 reporting organizations offered health insurance to some or all Caregivers/DSPs. On average, 24% (range 0% to 85%) of Caregivers/DSPs were enrolled in health insurance through their organization.
• In the West region, 64% of the 36 reporting organizations offered health insurance to some or all Caregivers/DSPs. On average, 15% (range 0% to 55%) 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: $39,526
• highest salary: $50,890
• average salary: $43,336

Figure 14 shows the average FLS starting, average, and highest salaries. Statewide, the average starting annual salary for FLSs was $39,526 (range $15,808 to $104,000). The overall average annual salary was $43,336 (range $5,000 to $104,000). The average highest annual salary was $50,809 (range $5,000 to $189,000).

• In the East region, the average starting annual salary for FLSs was $38,714 (range $24,000 to $54,317). The average annual salary was $40,886 (range $5,000 to $56,576). The average highest annual salary was $45,950 (range $5,000 to $65,000).
• In the Middle region, the average starting annual salary for FLSs was $40,280 (range $29,120 to $65,000). The average annual salary was $46,151 (range $32,000 to $79,976). The average highest annual salary was $52,510 (range $33,000 to $116,688).
• In the West region, the average starting annual salary for FLSs was $39,436 (range $15,808 to $104,000). The average annual salary was $42,543 (range $15,808 to $104,000). The average highest annual salary was $54,492 (range $15,808 to $189,000).

Frontline Supervisor Retention

FLS turnover is a key issue nationwide for stabilizing 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: 17%

Of those who left:

• left within 0-6 months of hire: 32%
• left within 6-12 months of hire: 28%

Statewide, the average annual turnover ratio for FLSs was 17%. By region, the FLS annual turnover ratio was 17% in the East, 18% in the Middle, and 18% in the West.

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

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

Within 0-6 Months of Hire

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

Statewide, the average FLS separation rate within 0 to 6 months of hire was 32%. By region, the average FLS separation rate within 0 to 6 months of hire was 28% in the East, 21% in the Middle, and 44% in the West.

Within 6-12 Months of Hire

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

Statewide, the average FLS separation rate within 6 to 12 months of hire was 28%. By region, the average FLS separation rate within 6 to 12 months of hire was 42% in the East, 27% in the Middle, and 16% in the West.

Frontline Supervisor Vacancy Rate

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

As seen in Figure 16, statewide, the average FLS vacancy rate was 6%. By region, the average FLS vacancy rate was 7% in the East, 6% in the Middle, and 4% in the West.

Revenue & Wage Costs

Statewide, the average total annual revenue for the 88 reporting organizations was $14,334,637 (range $13,000 to $739,131,400). The average payroll costs were $10,113,631 (range $6,000 to $445,899,393). Average total administrative costs (all non-program related expenses) were $625,232 (range $0 to $3,887,813). Average total expenses for training, employee assistance, and staff development were $60,980 (range $0 to $750,000). For the 82 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 64% (range 0% to 100%).

Direct Support Professionals and Frontline Supervisors Cohort Trends Over Time

Examining trends over time compares cohorts from each survey year rather than limiting analysis to only the same organizations over time. It is important to keep in mind that the samples for each year do not include the same organizations and may be substantively different.

Caregiver/DSP average scores for the annual turnover ratio, early turnover, vacancy rates, and hourly wages were examined to see how they changed over the six years. FLS average scores for annual turnover ratio, early turnover, vacancy rates, and salaries were examined to see how they operated over five years. The questions about FLSs were not asked in the first survey.

CAUTION SHOULD BE EXERCISED WHEN INTERPRETING TRENDS OVER TIME THAT ARE PRESENTED BELOW. SAMPLES FOR EACH YEAR TO NOT INCLUDE THE SAME ORGANIZATIONS AND MAY BE SUBSTANTIVELY DIFFERENT.

While we can discuss trends increasing or decreasing, caution needs to be taken with interpretation as we do not have the data to empirically understand what factors influenced the changes. In addition to changes in samples over the years, other major unanticipated events influencing the data over the six years included a tornado outbreak in March 2020, the COVID-19 pandemic beginning in April 2020, and wage increases that were implemented beginning in Tennessee in 2021. Increasing access to HCBS, strengthening the HCBS workforce and building 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 with augmentations. These events had an impact on 2020, 2021, and 2022 data although the degree of effect is unknown.

Direct Support Professionals Trends Over Time

Caregiver/DSP Retention Rates

Four measures of retention were computed and examined for Caregiver/DSPs. These included: annual turnover 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 2023. As seen in Figure 17, the average annual turnover in surveyed organizations was 46% in 2018, 47% in 2019, 63% in 2020, 57% in 2021, 61% in 2022, and 58% in 2023.

Early Caregiver/DSP turnover within 0-6 months of hire tells the percentage of Caregiver/DSPs who left their position within the first 6 months of starting the job. For Caregiver/DSPs, the average early turnover within 0-6 months of hire was 53% in 2019, 47% in 2020, 57% in 2021, 61% in 2022, and 55% in 2023.

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 between 6-12 months of hire was 33% in 2019, 22% in 2020, 28% in 2021 and 2022, and 24% in 2023.

Caregiver/DSP vacancy rate tells the percentage of vacant positions out of all of the Caregiver/DSP positions. The average Caregiver/DSP vacancy rate was 15% in 2018, 13% in 2019, 19% in 2020, 21% in 2021, 17% in 2022, and 13% in 2023.

Turnover

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

Early turnover (0-6 months)

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

Turnover (6-12 months)

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

Vacancy

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

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.

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, the average Caregiver/DSP starting hourly wage was $9.38 in 2018, $9.88 in 2019, $10.36 in 2020, $12.05 in 2021, $13.21 in 2022, and $14.55 in 2023. The average Caregiver/DSP hourly wage was $10.17 in 2018, $10.56 in 2019, $11.09 in 2020, $12.60 in 2021, $13.69 in 2022, and $15.01 in 2023. The average Caregiver/DSP highest hourly wage was $12.22 in 2018, $13.11 in 2019, $13.20 in 2020, $14.47 in 2021, $14.95 in 2022, and $16.69 in 2023.

Starting Hourly Wage

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

Hourly Wage

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

Highest Hourly Wage

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

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

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. These were not asked 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, 21% in 2020, 41% in 2021, 30% in 2022, and 17% in 2023. The average early turnover within 0-6 months of hire was 29% in 2019, 23% in 2020, 28% in 2021, 35% in 2022, and 32% in 2023. The average turnover within 6-12 months of hire was 28% in 2019, 29% in 2020, 51% in 2021, 46% in 2022, and 28% in 2023. The average vacancy rate was 13% in 2019, 16% in 2020, 15% in 2021, 22% in 2022, and 6% in 2023.

Turnover

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

Early turnover (0-6 months)

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

Turnover (6-12 months)

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

Vacancy

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

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.

Frontline Supervisor Salaries

Organizations provided data for FLS starting salary, annual salary, and highest salary. As seen in Figure 20, the average FLS starting salary was $31,187 in 2019, $31,552 in 2020, $34,180 in 2021, $37,177 in 2022, and $39,526 in 2023. The average FLS annual salary was $34,670 in 2019, $34,024 in 2020, $36,611 in 2021, $39,469 in 2022, and $43,336 in 2023. The average FLS highest salary was $42,654 in 2019, $38,731 in 2020, $43,629 in 2021, $44,797 in 2022, and $50,809 in 2023.

Starting salary

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

Average annual salary

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

Highest annual salary

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

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

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

As a reminder, caution should be exercised when interpreting trends over time presented in this report. Samples for each year do not include the same organizations and may be substantively different.

While none of the trends in retention measures or wages and salaries can be directly attributed to organization involvement in specific workforce training and consultation activities, there are trends worth noting. 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 study expanded to include CHOICES (Non-ECF CHOICES)/1115 Waiver providers.

For Caregiver/DSPs, prior to the pandemic (2018-2019), annual turnover was consistent at 46% and 47%, rose to 61% in 2022, and dropped to 58% in 2023. Early turnover within 0-6 months went up over time (53% in 2019 to 61% in 2022) but dropped to 55% in 2023. Turnover within 6-12 months of being hired decreased over time (33% in 2019 to 28% in 2021 and 2022 and 24% in 2023). Caregiver/DSP vacancy increased from 15% in 2018 to 21% in 2021 but declined to 13% in 2023. Starting, hourly and highest wages increased annually for Caregiver/DSPs.

For FLSs, turnover increased from 25% in 2019 to 41% in 2021 but decreased to 17% in 2023. Early turnover within 0-6 months of hire decreased initially from 29% in 2019 to 23% in 2020 but increased thereafter to 35% in 2022. There was a slight decrease to 32% in 2023. For turnover within 6-12 months of hire, rates were consistent in 2019 and 2020 (28%, 29%), increased to 51% in 2021, and decreased to 28% in 2023. FLS vacancy rates increased from 13% in 2019 to 22% in 2022. However, they dropped dramatically to 6% in 2023. FLS starting, annual, and highest salaries increased annually.

Discussion

Workforce Stability and Quality of Services

The state of the direct support workforce has a direct impact on the quality of services that older adults and people with disabilities receive. High-quality home and community-based services are needed to ensure that older adults and people with disabilities can be a part of their communities of choice, in ways that are meaningful to them. For this, a stable, committed, and highly competent direct support workforce is needed. Yet, turnover and vacancy rates remain at high levels for direct support workers across the United States, an issue that has remained notably consistent over many years.

Organizations in Tennessee continue to face challenges with recruiting, hiring, training, and retaining direct support professionals that can provide people with high quality supports, a challenge that serves as a key contributor to the shortage of direct support providers nationwide. While vacancies and turnover were lower this year, the vacancy rate was 13% (Figure 12) and the Caregiver/DSP turnover rate was 58% (Figure 13) which means that over half of the Caregiver/DSP workforce left their positions in 2023, and one out of every seven Caregiver/DSP positions were vacant. Vacancy rates are just below the national average (15.3% for full-time DSPs, 17.9% for part-time DSPs); however, the turnover rate is higher than national rates for DSPs (40.9%; NCI-IDD, 2023). The recruitment, hiring, training, and retention of direct support professionals remains challenging for organizations in Tennessee. It is imperative that continued investment in effective workforce solutions and strategies to overcome these workforce challenges to ensure that organizations and the direct support professionals they employee can provide home and community-based services that result in high-quality outcomes for older adults and people with disabilities in Tennessee.

Cost of Turnover

Staff turnover is 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 10,753 Caregivers/DSPs employed in 2023. Using the 25% of the Caregiver/DSP annual salary rule of thumb for cost of turnover and the average overall Caregiver/DSP wage of $15.01 per hour (Figure 8), costs of each Caregiver/DSP who leaves the position may be $7,805.20. At the rate of $7,805.20 per Caregiver/DSP, a 58% Caregiver/DSP annual turnover rate in the state of Tennessee results in an estimated $43,679,002 in costs related to Caregiver/DSP turnover. Eliminating even half of these costs could result in an annual $2,264 bonus per Caregiver/DSP for the 10,753 Caregivers/DSPs reported.

Caregivers/Direct Support Professionals Leave Their Positions Soon After Hire

Of the 58% of Caregivers/DSPs who left their positions in 2023, 55% left in the first six months of employment. An additional 24% of those left within six to twelve months of employment (Figure 13). This high rate of early leavers has been a persistent problem in TN since the second year of this initiative, when organizations first started reporting these numbers. These are high rates of Caregivers/DSPs leaving their position soon after starting, especially for providing the personalized, skilled supports required of many Caregivers/DSPs. For comparison, in organizations that employ DSPs in 29 states including the District of Columbia, 41.1% of DSPs who left their jobs in 2022 had been employed less than six months, and 21.2% who left had been employed between 6 and 12 months (NCI-IDD, 2023).

High rates of Caregivers/DSPs leaving early in their tenure (in 0-6 months or 6-12 months of hire) can signal the 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. It may also be indicative of job candidates entering positions without clear expectations about what the job entails. Without a comprehensive selection process, including utilizing a realistic job preview and clear job description so that candidates understand the job and implementing an interview process (such as structured behavioral interviewing) that allows the organization to choose the right person for the job, new hires may be unaware of what will be required of them on the job and may not be the right fit for the position. Others may leave if there is work available in another industry for similar or better pay. In 2023, as in previous survey years, Tennessee organizations have access to resources in the TN DSP workforce toolkit as well as training and consultation from the three MCO organizations to assist them in reviewing their current practices that are known to influence turnover in the first six months of hire. Some 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 preview and how to incorporate it into the selection process, structural behavioral interview guides, effective orientation, onboarding and peer mentoring and the importance of effective frontline supervision. 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 of turnover over time.

Vacancy Rates Influence Recruitment and Retention

Vacancy rate is a key indicator in measuring workforce stability (NCI-IDD, 2023). With historically high rates for this workforce sector, increases in vacancy rates have a corresponding effect on outcomes for people who rely on these services for support in their daily lives. In addition, when adequate DSP staffing cannot be secured and given the essential support services provided by these workers, existing workers are often asked to work long hours which is more likely to lead to burnout over time (Ejaz et al., 2015; Friedman, 2021a; Hall et al., 2024). The demand by people eligible for long term services and supports cannot be met without an adequate supply of DSPs and FLSs (Campbell et al., 2021). In Tennessee, the vacancy rate for Caregivers/DPSs in 2023 was 13% (see Figure 12). That rate is slightly lower than the national average and the trends over time show continued improvement since 2020. Nevertheless, there is still an ongoing need for more workers. Of equal importance is the vacancy rate for FLSs in Tennessee which dropped from 22% in 2022 to 6% in 2023 (see Figure 16).

Low Wages and Wage Compression

Organizations reported starting and average wages paid to Caregivers/DSPs. Across reporting organizations, the average starting hourly Caregiver/DSP wages were $14.55 per hour. The average Caregiver/DSP wages were $15.01 per hour. While they continue to increase in TN, these wages are still low when compared to nationwide wages. The average starting and average hourly wages for DSPs nationwide in 2023 were $15.13 and $15.79, respectively (NCI-IDD, 2023). Multiple studies have demonstrated the relation between wages and DSP turnover rates. Organizations that pay higher wages have lower turnover rates (Pettingell, Houseworth, et al., 2022; Houseworth et al., 2020).

Tennessee has enacted legislated pay rates for each of the last four years, increasing pay rates for entry level positions. The starting and average wages for Caregivers/DSPs only differs by $0.66, indicating an issue of wage compression, where those with high tenure and experience make close to the same rate as someone new to the field. This can cause those with higher tenure to leave the field. The challenge of increasing rates for tenured staff are now receiving attention through legislative and social recognition. Statewide, only 45% of organizations offer a wage increase for longevity, 50% offer a wage increase tied to performance, and 15% 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.

Limited Benefits

Access to benefits is another important factor for retaining 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. Sixty-five percent of organizations reported offering health (medical) insurance to some or all of their Caregivers/DSPs. However, those organizations reported an average of only 29% of Caregivers/DSPs who were actually enrolled in that benefit. It may be that the cost of health insurance (premium) 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 a study of over 1,400 provider agencies who completed the National Core Indicators 2016 Staff Stability Survey, provision of paid time off and health insurance to DSPs was a predictor of lower turnover rates (Houseworth et al., 2020). Exploring ways to provide these benefits may provide a cost savings to organizations by reducing Caregiver/DSP turnover.

Only 38% offered pooled paid time off (PTO), 20% paid sick leave, 31% paid vacation, and 21% paid personal time to some or all of their Caregivers/DSPs (Table 5). Direct support is demanding, and a profession with one of the highest injury rates in the nation (Bureau of Labor Statistics, 2020). Additionally, the stresses of living in poverty can make it difficult for Caregivers/DSPs to persist in this work without access to paid leave and other benefits such as health insurance. Examining and improving paid leave policies is another strategy to supporting this workforce.

Cost of Overtime

An important workforce issue for organizations is the level of Caregiver/DSP overtime hours and money paid out for overtime. Organizations reported overtime hours paid to full-time Caregivers/DSPs in 2023. Statewide, the average number of overtime hours that organizations paid out to full-time Caregivers/DSPs in 2023 was 23,369 (range 0 to 579,881), and the total number of overtime hours paid out in 2023 was 2,056,452 (Figure 10). The average cost of full-time Caregiver/DSP overtime in 2023 was $172,718 (range $0 to $4,154,847), and the total cost of full-time Caregiver/DSP overtime in 2023 was $14,853,713 (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.

Access to Support from Frontline Supervisors

Another 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. Seventeen percent of FLSs left their positions in 2023, with 32% of those frontline supervisors leaving with 0-6 months of hire (Figure 15). There was a 6% 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. Continuing to offer 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, is 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 began in 2024. All open seats have been utilized, and over 600 direct support workers (including FLS roles) have received certifications through September. As of September 30, 2024, 54 FLS are participating in the NADSP E-Badge Academy (https://www.tn.gov/tenncare/long-term-services-supports/systems-transformation/e-badge-academy.html). 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.

Reasons for Leaving

Stay surveys, stay interviews, and satisfaction surveys are becoming more popular and recommended in 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 2023, according to organizations, were “No call/No show”, "Found another job at another company", and "Was terminated/fired". While it is often difficult to know the reason Caregivers/DSPs leave, organizations can instead work to understand the reasons they stay and build on those positive attributes.

Recommendations

Survey and Data Collection

In monitoring direct support workforce trends related to turnover and vacancy rates as well as wages, it is vital to not only continue to understand the sample, but also improve its representativeness and gather good quality data. It is important for the MCOs and TennCare to continue to ensure adequate resources are available for survey development and implementation, data collection, and ongoing analyses.

Sample

A strong understanding of the survey participants is important. 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. Participants in this study included providers supporting the ECF CHOICES/1115 Waiver population from intellectual and developmental disabilities sector, providers supporting the CHOICES (Non-ECF CHOICES)/1115 Waiver population from the aging and disability sector, and those providing supports to both population sectors. MCOs have been working to understand and grow a representative sample of organizations providing supports to these populations. In year 6, the MCOs implemented eligibility criteria at the beginning of the survey to gather data from organizations on which criteria, if any, they did not meet. This allowed an opportunity for follow-up conversations with organizations to understand what had changed affecting their eligibility. As data collection efforts continue, a thorough evaluation of the sample frame for the purposes of removing organizations that are no longer participating in ECF CHOICES/1115 Waiver or CHOICES (Non-ECF CHOICES)/1115 Waiver or do not meet eligibility criteria and including organizations new to these funding mechanisms 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 this process. It is time-consuming but extremely important to have quality and sufficient data to implement solutions for enhancing the stability of the workforce. Establishing accurate contact information at each organization prior to the survey launch is ideal. Several communications may be necessary before the correct contact person is found. Exchanging communications with the survey contact(s) throughout the data collection period helps build rapport and ensure they feel supported in their data reporting efforts. Once the survey cycle ends, updating contact information on a regular basis is recommended. During the data collection timeframe, MCO data collection teams have been intentional with consistent follow-up with organizations who have not submitted their surveys. It is important to continue this practice. Continuing to develop and grow relationships with the organizations so they understand the importance of their data contribution is one of the key factors influencing organizations to participate and provide quality data.

In addition to relationship building, there are specific data issues to consider as well. There are multiple sources of data that can provide an understanding of the Caregiver/DSP workforce. The collection of quantitative data from the annual survey provides information on key workforce metrics (e.g., vacancy, turnover, wages, offering of benefits, etc.); however, it does not include details about what may be driving these metrics. Using additional 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.

Additionally, monitoring workforce data trends over time is essential to understanding whether workforce solutions that have been implemented are successful or where they need to be modified or changed. To do this most 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.

Survey & Data

MCOs have listened to feedback provided by organizations around the annual survey. They adjusted the survey to improve the survey experience for organizations. Efforts have been made to provide clear directions, definitions, and methods for data computations; however, there is still a need to refine them as when these are unclear, the possibility of errors due to misunderstanding is introduced.

Given there are multiple populations of interest, consideration should be given to analyzing and understanding the direct support workforce who provides services to people with IDD and those who provide services to people in the aging/disability sectors, separately. Although overlapping at times, the needs of the individuals supported are different, and Caregivers and DSPs often differ in their skills, responsibilities, and scope of work. When included altogether, the interpretation of results is less clear and comparability to national workforce benchmarks is limited. There is precedent for collecting them separately as is done at the national level using the State of the Workforce National Core Indicators Intellectual and Developmental Disabilities (NCI-IDD) and National Core Indicators Aging and Disabilities State of the Workforce (NCI-AD) surveys. That also needs to be evaluated with the burden of data requested.

The University of Minnesota is building the Direct Support Workforce Solutions Supportwise Data Portal. This tool is for organizations and allows them to collect and track key workforce data elements, analyze their data in real time and over time, and provides comparisons to national benchmarks (where appropriate) from the NCI-IDD survey and, in the future, NCI-AD survey. Additionally, directions, definitions, and automated calculations provide reliability and validity of the data submitted by organizations. This system may be an option for future Tennessee surveys as it could service the needs of the organizations, the MCOs, and TennCare while bringing consistency to terminology, computation of key workforce metrics, and data comparisons. Ultimately, it is high quality data that plays a role in informing data driven solutions that can improve workforce recruitment, retention, and stability.

Ongoing Support for Provider Organizations in Workforce Development

The challenges with workforce recruitment and retention persist. As the gap between the number of committed and competent Caregivers/DSPs and the demand for those Caregivers/DSPs widens, it is more important than ever for provider organizations in Tennessee to find ways to overcome these workforce challenges. A key component in doing so involves the identification, understanding, and implementation of workforce strategies that strengthen the direct support workforce thereby reducing the turnover and vacancy of Caregivers/DSPs and contributing to higher quality outcomes for the people receiving services. Supporting organizations to implement these workforce strategies allows them to find and keep competent and committed direct support staff. Continued emphasis on building MCOs’ capacity for providing organizations with targeted, ongoing training and technical assistance is needed. MCO workforce development efforts should include supporting organizations with using key workforce data to identify their unique workforce challenges, prioritize the implementation of workforce strategies, and evaluate the effectiveness of implemented workforce strategies. Organizations can benefit from this systematic approach to technical assistance that uses current best practices in workforce development by gaining the ability to measure and monitor their recruitment and retention efforts overtime.

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 such as pay for performance-based.

Strong Recruitment Marketing Efforts Can Attract and Recruit New and Diverse Staff

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, thereby reducing the discrepancy between the number of people interested in getting into the field and the demand for committed workforce. Organizations can use best practices in recruitment marketing when high vacancy rates are a workforce challenge that they experience.

Developing community partnerships and utilizing other community outreach efforts like public service announcements (PSAs) and targeted marketing flyers that are available through a partnership between TennCare, TNCO, and ICI can elevate and shed light on the role of the direct support workforce within their community.

Leveraging the voices of current Caregivers/DSPs within an organization can help in soliciting new and diverse workforce members to the team. Organizations can utilize referral bonuses to motivate current staff (which are currently only offered by 55% of organizations) to refer quality workforce members or teach Caregivers/DSPs to use their voice as an authentic and powerful message about the many great reasons they became a Caregiver/DSP and why they stay.

Organizations in Tennessee need to continue to prioritize recruitment marketing efforts that incorporate the systematic and coordinated implementation of best practices in attracting and recruiting a new and diverse workforce. The TN DSP Workforce Toolkit, developed by TennCare, in partnership with the University of Minnesota, offers a number of evidenced based recruitment and marketing tools and strategies for use by organizations. Individualized support with 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 and Hiring the Right Staff Can Increase the Retention of a Committed and Qualified Workforce

Organizations in Tennessee continue to experience difficulties with early turnover, as many newly hired direct support staff leave the position within the first year of being hired, or even within the first 6 months. This further contributes to a high number of workforce vacancies within an organization and can have costly financial impacts. The roles and responsibilities of Caregivers/DSPs and FLSs are not only highly valuable, but complex.

During the hiring process, there may be pressure to fill vacancies by hiring candidates without adequate qualifications, experience, and attitudes toward people with disabilities. Candidates selected in this manner often make turnover worse or result in a less-qualified workforce. Structured behavioral interviewing, an evidence-based strategy that asks questions designed to seek behavioral responses, is used to ensure qualified candidates who are well matched to the position and employer are selected for hire. A standardized scoring protocol can be used to support systematic and consistent decision making about which candidates are best matched to the organization and position and who is ultimately offered the job.

Realistic job previews (RJPs), such as the RJP made available to providers through a partnership with TennCare, TNCO, and ICI, can be used during the hiring and selection process to ensure that applicants have a realistic understanding of the role of a Caregiver/DSP, including a balance of the positives and the challenges that are involved. Applicants can decide themselves if they are a good fit for the job, and prior to committing, self-select out if they decide they are not. New hires, who have been systematically selected to join the team based on their qualifications, experiences, attitudes and level of fit for the job, 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 use of best practices and workforce tools and strategies in selection and hiring, like the Tennessee specific realistic job preview and other tools in the TN DSP Workforce Toolkit, can support organizations with improving the recruitment and retention of their workforce.

A Focus on Competency-Based Career Growth and Advancement Can Help Retain the Current Workforce

Turnover is not only occurring at high rates within a Caregivers/DSPs first year, but for those with longer tenure as well. With the demand for the workforce exceeding the number of people available to enter the field, it will be important for organizations to focus on retaining the workforce that they already have. 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.

The implementation of a competency-based workforce model allows organizations to partner in the process of professionalizing the Caregiver/DSP role, by elevating workforce roles to align with the level of complexity and responsibility that people in those roles experience and endure. Competencies are foundational skills needed to perform a job. DSP and FLS competencies can be used 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 credentialling programs, such as the NADSP E-Badge Academy, made available by TennCare, empowers people in direct support roles to develop themselves professionally by seeking a level of advancement in their position, envisioning the role as a career versus a job and feeling more motivated to stay. Wage increases can also be tied to the increased skills, knowledge, efforts, and responsibilities that come along with advancement in career pathways or credentialling. 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 use of workforce retention practices like these elevates the DSP role, helps DSPs improve their skills and abilities, increases the quality of services, and reduces turnover.

Conclusion

This survey is part of a comprehensive effort to learn about and support the direct support workforce in Tennessee. This sixth annual survey report includes important findings to inform data-driven solutions to support organizations to recruit, hire, and retain Caregivers/DSPs. These data, especially when paired with training and consultation on workforce solutions where available to participating organizations, are intended to address the workforce crisis when implemented with fidelity over time. Organizations that participate are well-positioned to see a more stable and highly trained workforce over time. These data provide an additional data point about the status of the Caregiver/DSP workforce issues among the 114 participating organizations.

References

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