Employment and Community First CHOICES Workforce QuILTSS Initiative Survey 2020: Year Three Report

The Institute on Community Integration (ICI) at the University of Minnesota worked in collaboration with Amerigroup, UnitedHealthcare, and Blue Cross Blue Shield TN, TennCare and Tennessee Community Organizations (TNCO) to develop and administer the Employment and Community First CHOICES QuILTSS Workforce Initiative 2020 Survey, analyze the data, and report the results.

This survey is part of a larger project in which TennCare is collaborating with TNCO and ICI at the University of Minnesota to address workforce challenges for direct support professionals (DSPs) in Tennessee. The survey is a key component of a comprehensive workforce strategy in the Quality Improvement in Long-Term Services and Supports (QuILTSS) Initiative. As part of this comprehensive effort, data gathered from the first two years of the survey are informing ongoing discussions and planning about wages, benefits, and ways to find and keep good employees and enhance access to home and community-based services (HCBS) for people with intellectual and developmental disabilities in Tennessee. Participating organizations received a profile about the direct support workforce in their organization. They also received training and technical assistance to identify and address at least one key challenge that their organization faces to improve their direct support workforce turnover and retention rates. 

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

Project technical assistance team from the University of Minnesota included: Barbara Kleist, Sarah Hall, Claire Benway, Laurie Tschetter, Julie Kramme, Megan Sanders, Mark Olson, and Amy Hewitt.

Suggested citation

• Pettingell, S., Hewitt, A., Kleist, B., Sanders, M., Hall, S., Kramme, J., & Zhang, A. (2021). Employment and Community First CHOICES Workforce QuILTSS Initiative Survey 2020 Year Three Report. Minneapolis: University of Minnesota, Institute on Community Integration, Research and Training Center on Community Living.

Background

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

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

The direct support workforce continues to be among occupations with the highest growth rate in the United States. It has grown significantly in the last decade from three million to 4.6 million workers in 2019, and it is expected to grow to include another one million workers by 2028 (Campbell et al., 2021). The demand for workers exceeds the number of new workers wanting to enter this profession. This results in sustained high vacancy rates and staff shortages. Organizations struggle to retain workers after they are hired due to competition for workers with other industries, low wages, and access to affordable benefits. This direct support workforce shortage is an ongoing crisis across the U.S. and is particularly challenging within Home and Community Based Services (HCBS) for persons with intellectual and developmental disabilities (IDD; Scales, 2020). In Tennessee and across the U.S., the State Medicaid Agency goals are to decrease the number of people in institutional settings and increase the use of HCBS programs to address waiting lists for services. These goals cannot be met without strategic efforts to ensure a sufficient and stable number of DSPs available to provide community services. People with disabilities who experience greater DSP turnover have more injuries and instances of abuse and neglect. The health and safety of people with disabilities increases when DSPs have longer tenure (Friedman, 2021a). Community living for people with disabilities is also compromised when effective and timely solutions to the DSP workforce shortage are not available, funded, and evaluated.

There is a critical need for collection, analysis, and use of provider, program, and state level comprehensive workforce data to identify and match interventions to recruit and retain DSPs in organizations that provide services and supports to people with IDD. Interventions such as ongoing staff development, can significantly improve the services of an organization as well as the health and safety of the people they serve (Friedman, 2021b). In order to positively impact the workforce crisis, organizations need to learn skills to improve their recruitment, selection, and retention of DSPs (PCPID, 2017). This includes assessing and responding to the added burden placed on an already unstable workforce by COVID-19. This global pandemic was declared by the World Health Organization in March of 2020, impacting the delivery of services to people receiving long term services and supports and their DSPs. In fact, aging and having an intellectual disability are two of the strongest risk factors for dying from the COVID-19 pandemic (Gleason et al., 2021). This places human service organizations and DSPs in an integral role in supporting health and safety in the midst of the pandemic. In the past year, several studies were initiated to address the impact COVID-19 is having on the workforce. In a 2020 survey of over 1,600 community provider organizations in all fifty states and the District of Columbia who provide long term services and supports for people with IDD, 68% reported closure of one or more services due to the COVID-19 pandemic (Avalere, 2020). This resulted in an average 32% loss of revenue. Organizations also experienced significant staffing challenges. In a survey of over 8,800 DSPs from all fifty states, DSPs reported differences in staffing and schedules since the start of the pandemic (Hewitt et al., 2020). Forty-four percent reported working more hours, 43% have different work responsibilities or roles, 35% work different shifts, and 28% worked in different settings since the start of the pandemic. While adequate staffing was a widespread issue among organizations that employ DSPs before the pandemic, only 55% of DSPs indicated that the locations where they worked were adequately staffed during the pandemic (Hewitt et al., 2020). The impact of the COVID-19 pandemic on the DSP workforce is continuing to be assessed as organizations carry out business while still working to prevent people with disabilities and those who are aging from becoming infected by COVID-19.

TennCare is Tennessee’s state Medicaid program and administers services to over 1.4 million people. As part of a statewide workforce initiative, TennCare sought a method to regularly collect, analyze, and use provider, program, and state level comprehensive workforce data for its Managed Long-Term Supports and Services (MLTSS) that support HCBS programs for people with disabilities. This effort is connected to the Quality Improvement in Long-Term Services and Supports (QuILTSS) Initiative. This is the third year of the QuILTSS Initiative survey, which was completed by disability provider organizations that deliver Employment and Community First CHOICES in Tennessee and employ DSPs. This report presents the summary of data from 63 provider organizations that completed the survey regarding their workforce in those programs.

Year Three Methodology

Year Three Survey Development & Administration

The year three survey (using calendar year 2020 data) maintained the same format as that of year two with one exception. A section of two items was added to gather information on how the COVID-19 pandemic impacted the organization. It was important to have this additional context in order to more accurately interpret and understand the data. These additional items were sent to TennCare and the Managed Care Organization (MCO) leads from Amerigroup, Blue Care of Tennessee, and United Healthcare for their approval before they were incorporated into the survey. The finalized survey was converted into an online Qualtrics survey. An internal pilot test was conducted to assure the new COVID-19 items functioned as intended. Since the main content and format of this survey was the same as year two, there was no need for an external pilot test. The year three survey was launched on June 1, 2021. A webinar was delivered on June 7, 2021 for all organizations invited to complete the year three survey. The purpose of the webinar was to provide an introduction to the survey, clarify issues that were more difficult for participants in year two, and to answer questions. It was recorded and made available on demand for organizations who were unable to attend and as a resource for all organizations to reference as they were completing the survey. The survey deadline was originally July 9, 2021. Due to the COVID-19 pandemic and organizations needing more time, the survey deadline was extended to July 23, 2021. The survey was closed on July 23, 2021. During data cleaning, a follow-up was completed with all organizations with data inconsistencies or required clarifying information. Clean-up and analyses were conducted from July 26, 2021 to August 13, 2021.

Recruitment, Sample, and Response Rate

At the onset of year one, the list of organizations that employed DSPs and participated in Employment and Community First CHOICES included 114 organizations located within the three regions of Tennessee. MCOs reviewed this original TennCare list for year three. Of those 124 organizations, 26 (21%) either dropped out or opted out of the year three survey and did not receive a survey link. Some organizations did not provide ECF CHOICES services at this time, merged with another organization, were duplicate contacts, or did not have staff to complete the survey at this time. This left a sample of 98 organizations who were sent an invitation letter by email with links to participate in the year three survey.

MCOs verified each organization’s address, primary contact person, and that person’s contact information. The UMN Data Collection Team also verified the contact information. ICI drafted an invitation letter to the organizations in the sample, and MCOs reviewed and distributed the letter. The letter introduced the survey to the organizations by communicating its purpose, how the data would be used, how it would be helpful to them, and encouraged participation.

Of the 98 participants in year three, 63 (64%) submitted a year three survey, 8 (8%) only opened/started the survey but did not complete it, and 27 (28%) did not respond at all. Of the 63 submitted surveys, 33 (53%) participated in both the year one and two survey, 4 (6%) participated in the year one survey but not year two survey, 17 (27%) participated in the year two survey but not year one survey, and 9 (14%) were new participants. The 63 organizations who submitted a survey were included in the year three analysis. Organizations were grouped into three regions for the regional analysis. Regional analyses were conducted based on the region where the organization provided the highest percentage of their services, which may differ from the location of their administrative/corporate/central office. Of the 63 organizations, 21 (33%) provided their highest percentage of service in the East counties, 31 (49%) provided their highest percentage of service in the Middle counties, and 11 (18%) provided their highest percentage of service in the West counties. There were two organizations that provided an equal percentage of services in multiple regions, meaning there was no highest region. In those instances, their region was assigned by where their home office was located.

63 organizations completed the year three survey reporting on calendar year 2020. 75 organizations completed the year two survey reporting on calendar year 2019. 47 organizations completed the year one survey reporting on calendar year 2018.

Year Three Results

This report provides an overview of state level survey data. State and regional profiles are available in Appendix A. Survey items were analyzed by region when there was a large enough sample size for analysis.  Regional breakdowns were based on where the organization’s highest percentage of services were located. Unless otherwise specified, responses to survey questions reflect calendar year 2020. The first sections of the report focus on the results from year three. The last section of the report presents results about the change from year one to year three. It is important to note that while 63 organizations participated in the survey, not all organizations answered all questions. Additional qualitative data is provided throughout the report regarding project activities and outcomes.

Organization Background

For the purpose 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

Figure 1 indicates the percent of services that 63 organizations provided in the East, Middle, and West regions of Tennessee. In the state, 35% of organizations provided services in the East region, 48% provided services in the Middle region, and 17% provided services in the West region.

When looking at administrative office headquarters, 32% (20 organizations) had their administrative office in the East, 54% (34 organizations) were located in the Middle, and 14% (9 organizations) were located in the West. The majority of organizations provided services in one region (81%), though 8% provided services in two regions and 11% provided services in three regions. Of the 63 organizations who provided information on the regions they served, 46% provided services in the East region, 57% provided services in the Middle region, and 27% provided services in the West region. The total percentage of services in each region adds up to more than 100% as some organizations work in more than one region.

As seen in Figure 2, most organizations statewide (88%) have been in business for 10 or more years, 6% for 6 to 10 years, 6% for 1-5 years, and none for less than one year. In comparison, most organizations statewide (83%) have provided services for 10 or more years, 11% for 6 to 10 years, 13% for 1 to 5 years, and none for less than 1 year.

Figure 3 summarizes the percentage of service sites where services are provided by the organizations across the state. Organizations provided services in several settings, including agency/facility sites, family or individual homes, job sites, and other sites. Statewide, organizations most often provided services in family or individual homes (59%), followed by agency or facility sites (20%), job sites (17%), and other sites (4%). The other category includes all sites that did not fit into the listed service site categories.

In the East, 25% of organizations provided services in agency or facility sites, 54% provided services in family or individual homes, 20% provided services in job sites, and 1% provided services in other settings.  In the Middle, 20% of organizations provided services in agency or facility sites, 59% provided services in family or individual homes, 18% provided services in job sites, and 3% provided services in other settings.  In the West, 10% of organizations provided services in agency or facility sites, 70% provided services in family or individual homes, 9% provided services in job sites, and 11% provided services in other settings.

People Served

DIDD = Department of Intellectual and Developmental Disabilities

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 (1915c), ECF CHOICES, CHOICES (Non-ECF CHOICES), and VR services.  Across the state, the average number of people for whom organizations provided DIDD, ECF CHOICES, CHOICES, and/or VR services was 115 people (range 1 to 667). The average number of people served in the East region was 101 (range 1 to 436) in 21 organizations. The average number of people served in the Middle region was 98 (range 15 to 454) in 31 organizations. The average number of people served in the West region was 190 (range 15 to 667) in 11 organizations.

Organization Staffing

The organizations who responded to the survey supported 7,267 people with disabilities and employed a total of 10,289 staff.  As seen in Figure 4, this included:

• 7,333 DSPs
• 629 frontline supervisors (FLSs)
• 344 managers
• 716 administrators, and
• 1,267 other staff.

In the East region, there were 2,133 people served by 21 organizations with supports from 2,346 DSPs and 184 FLSs. There were 183 managers, 271 administrators, and 690 other staff. There were 3,674 total staff in the East.

In the Middle region, there were 3,039 people served by 31 organizations with supports from 3,530 DSPs and 212 FLSs. There were 104 managers, 328 administrators, and 217 other staff. There were 4,391 total staff in the Middle.

For the West region, there were 2,095 people served by 11 organizations with supports from 1,457 DSPs and 233 FLSs. There were 57 managers, 117 administrators, and 360 other staff. There were 2,224 total staff in the West.

On average across the state, organizations employed 118 DSPs, including on-call, temporary, and relief positions; 10 FLSs; 6 managers; 12 administrators (e.g., administrative, executive director, human resources/payroll); and 20 other employees.

Organizations were asked to report the number of full-time, part-time, and on-call DSPs they employ.  There were 13 (21%) organizations that were unable to distinguish between full-time and part-time DSPs. Of the reporting organizations, across the state, 66% were full-time DSPs, 30% were part-time, and 4% were on-call/temporary or relief staff. Sixty-two percent of DSPs worked across more than one service type. Figure 5 shows this DSP staffing pattern in the state.

There were some regional differences in DSP staffing patterns.

• In the East, 79% were full-time, 20% were part-time, and 1% were on-call/temporary or relief staff. Fifty-six percent of the DSPs worked across more than one service type.
• In the Middle, 63% were full-time, 34% were part-time, and 3% were on-call/temporary or relief staff. Sixty-eight percent of the DSPs worked across more than one service type.
• In the West, 55% of DSPs were full-time, 36% were part-time, and 9% were on-call/temporary or relief staff. Thirty-eight percent of the DSPs worked across more than one service type.

Organizations were asked how they defined part-time and full-time positions. Of the 62 organizations who responded, 21% of organizations across the state indicated that they could not differentiate between full-time and part-time DSPs. Most organizations defined their part-time and full-time positions by the number of hours worked per week. Of the 51 organizations who specified the number of hours per week a DSP needs to work to be considered full-time, 6% required DSPs to work 29 hours per week or less, 39% at least 30-34 hours, 16% at least 35-39 hours, and 37% at least 40 hours per week. One organization selected the other category and indicated that full-time staff are only designated as full-time when hired into full-time positions no matter the number of hours they work.

For the 15 organizations in the East region who specified the number of hours per week a DSP needs to work to be considered full-time, 20% required DSPs to work 29 hours per week or less, 27% at least 30-34 hours, 13% at least 35-39 hours, and 40% at least 40 hours per week. For the 28 organizations in the Middle region who specified the number of hours per week a DSP needs to work to be considered full-time, 43% required DSPs to work at least 30-34 hours, 18% at least 35-39 hours, 36% at least 40 hours per week, and 3% selected the other category. One organization selected the other category and indicated that full-time staff are only designated as full-time when hired into full-time positions no matter the number of hours they work. For the 8 organizations in the West region who specified the number of hours per week a DSP needs to work to be considered full-time, 50% required DSPs to work at least 30-34 hours, 12% at least 35-39 hours, and 38% at least 40 hours per week.

Direct Support Professionals

DSP Wages

Organizations reported on the wages paid to DSPs, including starting wages, average wages, and highest wages paid on December 31, 2020. Organizations reported regular wages paid and did not include overtime wages. All data about wages were reported for part-time DSPs, full-time DSPs, and all DSPs.  Among all DSPs statewide, the average wages are indicated in Figure 6. The average starting wage for all DSPs was $10.36, the overall average wage for all DSPs was $11.09, and the average highest wage for all DSPs was $13.20.

Organizations were asked to report whether DSPs who work in different service types are paid the same wage for each service. In the East and Middle regions, 18% of organizations pay DSPs different wages for each service type. The West region was higher, with 27% paying different wages for each service type.

Starting DSP Wages

The average starting wage for all DSPs was $10.36 (range $8.00 to $18.00). The average starting wage for full-time DSPs was $10.46 (range $8.00 to $18.00). The average starting wage for part-time DSPs was $10.27 (range $8.00 to $12.00). These wages are depicted in Figure 7.

The number of responding organizations is in parenthesis.

• The average starting wage was similar across regions. In the East, the average starting wage for all DSPs was $10.04 (range $8.00 to $11.73). The average starting wage for full-time DSPs was $9.95 (range $8.00 to $11.25). The average starting wage for part-time DSPs was $10.02 (range $9.25 to $11.00). 
• In the Middle, the average starting wage for all DSPs was $10.72 (range $9.00 to $18.00). The average starting wage for full-time DSPs was $10.92 (range $9.00 to $18.00).  The average starting wage for part-time DSPs was $10.51 (range $9.00 to $12.00). 
• In the West, the average starting wage for all DSPs was $9.97 (range $8.00 to $12.50). The average starting wage for full-time DSPs was $9.94 (range $8.00 to $12.00).The average starting wage for part-time DSPs was $9.94 (range $8.00 to $12.00). 

 Average DSP Wages

The number of responding organizations is in parenthesis.

Organizations reported their average wages for part-time, full-time, and all DSPs. The average wage for all DSPs was $11.09 (range $9.00 to $20.00). The average full-time DSP wage was $12.01 (range $9.00 to $40.00). The average part-time DSP wage was $11.03 (range $10.00 to $15.00). These wages are depicted in Figure 8. As with the starting wages, there was little variation in DSP average hourly wages by region.

• In the East, the average wage for all DSPs was $10.88 (range $9.00 to $12.39). The average wage for full-time DSPs was $11.23 (range $9.00 to $14.64). The average wage for part-time DSPs was $11.04 (range $10.00 to $13.00).
• In the Middle, the average wage for all DSPs was $11.50 (range $9.59 to $20.00). The average wage for full-time DSPs was $12.98 (range $10.00 to $40.00). The average wage for part-time DSPs was $11.23 (range $10.00 to $15.00). 
• In the West, the average wage for all DSPs was $10.36 (range $9.00 to $12.50). The average wage for full-time DSPs was $10.58 (range $10.00 to $12.00). The average wage for part-time DSPs was $10.49 (range $10.00 to $12.00). 

Highest DSP Wages

Organizations were asked to report the highest wages paid to DSPs in their organization by full-time, part-time, and all DSPs. The average highest wage for all DSPs was $13.20 (range $9.00 to $25.00). The average highest wage for full-time DSPs was $13.59 (range $9.00 to $25.00). The average highest wage for part-time DSPs was $12.32 (range $10.00 to $16.00).

• In the East, the average highest wage for all DSPs was $12.86 (range $9.00 to $16.50). The average highest wage for full-time DSPs was $13.55 (range $9.00 to $17.24). The average highest wage for part-time DSPs was $12.13 (range $10.00 to $16.00).
• In the Middle, the average highest wage for all DSPs was $13.56 (range $10.00 to $25.00). The average highest wage for full-time DSPs was $13.81 (range $11.00 to $25.00). The average highest wage for part-time DSPs was $12.19 (range $10.00 to $15.00).
• In the West, the average highest wage for all DSPs was $12.84 (range $9.00 to $17.50). The average highest wage for full-time DSPs was $13.06 (range $10.50 to $17.50). The average highest wage for part-time DSPs was $12.95 (range $11.50 to $14.26). 

DSP Wage Increases & Bonuses

Organizations were asked to report on whether they provided wage increases to DSPs in three different ways and the average amount they paid for each wage increase. Additionally, organizations reported on whether they provided different types of bonuses to DSPs and the average amount they paid for calendar year 2020.

Hourly Wage Increases

Wage Increases after Training was Completed

Organizations were asked whether they routinely gave an hourly wage increase for DSPs after training was completed. Regional data for the amount of wage increases were reported by a small number of organizations, so interpret with caution. Monetary amounts for wage increases or bonuses were also reported by a small number of organizations, so interpret with caution.

	Once training was complete
	State		East		Middle		West
	N	% yes	N	% yes	N	% yes	N	% yes
All DSPs	63	40	21	38	31	48	11	18
Part-Time	17	88	5	80	11	91	1	100
Full-Time	17	94	5	100	11	91	1	100

	Longevity
	State		East		Middle		West
	N	% yes	N	% yes	N	% yes	N	% yes
All DSPs	63	27	21	24	31	32	11	18
Part-Time	10	90	2	100	7	86	1	100
Full-Time	11	91	2	100	8	88	1	100

	Other than longevity
	State		East		Middle		West
	N	% yes	N	% yes	N	% yes	N	% yes
All DSPs	62	32	21	43	30	33	11	9
Part-Time	13	69	6	67	6	67	1	100
Full-Time	13	92	6	100	6	83	1	100

N = The number of organizations answering each question.

% = The percent out of the total organizations.

As seen in Table 1, 40% of organizations across the state provided an hourly wage increase for DSPs once training was completed. Of the organizations who provided an hourly wage increase and responded specifically for part-time and full-time DSPs, 88% gave an hourly wage increase for part-time DSPs and 94% for full-time DSPs. In the East region, 38% of organizations gave an hourly wage increase for DSPs once training was completed. Of the organizations who were able to provide data for part-time and full-time DSPs, 80% reported an hourly wage increase for part-time DSPs and 100% for full-time DSPs. In the Middle region, 48% of organizations reported an hourly wage increase for DSPs once training was completed. Of the 11 organizations who were able to break their data down by part-time and full-time DSPs, 91% gave an hourly wage increase for part-time and full-time DSPs. In the West region, 18% of organizations reported an hourly wage increase for DSPs once training was completed. The one organization who was able to provide data for part-time and full-time DSPs gave an hourly wage increase for both.

The average increase of hourly wages in the state after training was completed was $0.67. By region, the average hourly wage increase after training was completed was $0.53 in the East and $0.73 in the Middle. No hourly wage increase amount was available for the West region.

Wage Increases for Longevity

Organizations were asked whether DSPs earned hourly wage increases for longevity of employment (e.g., end of first year, after three years) in 2020. Statewide, 27% of organizations provided an hourly wage increase to DSPs for longevity. Of the organizations who were able to provide data for part-time and full-time DSPs, 90% offered hourly wage increases for longevity for part-time DSPs and 91% offered hourly wage increases for longevity for full-time DSPs. The percent of organizations who provided hourly wage increases for longevity varied across the regions of Tennessee. In the East region, 24% of organizations gave hourly wage increases for longevity to DSPs. Of the 2 organizations who were able to provide data for part-time and full-time DSPs, 100% offered an hourly wage increase for longevity to both part-time and full-time DSPs. In the Middle region, 32% of organizations gave an hourly wage increase to DSPs for longevity. Of the organizations who were able to provide data for part-time and full-time DSPs, 86% offered an hourly wage increase to part-time DSPs and 88% to full-time DSPs. In the West region, 18% of organizations gave hourly wage increases for longevity to DSPs. For the organization who was able to provide data for part-time and full-time DSPs, 100% offered to part-time and full-time DSPs (see Table 1). The average amount of wage increase for longevity across the state was $0.79 for all DSPs. By region, the average amount of wage increase for longevity was $0.47 in the East, $1.03 in the Middle, and $0.50 in the West.

Wage Increases Offered by Months After Hire	% Organizations Offering
1-3 Months	6%
4-6 Months	19%
7-9 Months	0%
10-12 Months	81%

Number of organizations reporting: 16

Organizations indicated at which points they offer wage increases based on number of months post hire. They could check all that applied to their organization’s practices for when they offer these wage increases to DSPs. Table 2 shows the points when these increases are given after a DSP is hired. Of the organizations who gave hourly wage increases for longevity, 6% gave an hourly wage increase for longevity at 1-3 months, 19% gave one at 4-6 months, 0% gave one at 7-9 months, and 81% gave an hourly wage increase for longevity at 10-12 months for all DSPs. There were insufficient responses to report out at the regional level.

Other Wage Increases

The survey also asked organizations if they offered hourly wage increases to DSPs for reasons other than longevity in 2020. As seen in Table 1, 32% of the organizations provided wage increases for reasons other than longevity across the state. Of the organizations that were able to provide data for part-time and full-time DSPs, 69% offered wage increases for reasons other than longevity to part-time DSPs and 92% to full-time DSPs. The percent of organizations who gave hourly wage increases for reasons other than longevity varied across the regions of Tennessee. In the East region, 43% of organizations gave hourly wage increases for reasons other than longevity to DSPs. Of the organizations who were able to provide data for part-time and full-time DSPs, 67% offered an hourly wage increase for reasons other than longevity to part-time DSPs and 100% to full-time DSPs. In the Middle region, 33% of organizations gave hourly wage increases for reasons other than longevity to DSPs. Of the organizations who were able to provide data for part-time and full-time DSPs, 67% offered it to part-time DSPs and 83% to full-time DSPs. In the West region, 9% of organizations gave hourly wage increases to DSPs for reasons other than longevity. For the organization who was able to provide data for part-time and full-time DSPs, 100% offered it to part-time and full-time DSPs. The average amount of this hourly wage increase for reasons other than longevity was $0.69 across the state, $0.48 in the East region, and $0.89 in the Middle region for DSPs. No hourly wage increase amount was available for the West region.

DSP Bonuses

Questions about monetary referral, hiring, years of service, and performance recognition bonuses were added to the year three survey. Organizations may give referral bonuses to current employees to encourage inside recruitment. The employees share information about the work to people they know whose skills and interests are a good fit for the position. The referral bonus is generally given to the employee after the new hire remains in the position for at least 6 to 12 months to ensure qualified, interested individuals are recruited. Alternately, hiring bonuses are generally provided to the newly hired employee as an incentive to attract individuals to the organization. Part of the hiring bonus should be paid shortly after hire, and part should be paid 6 to 12 months after hire. A bonus for years of service may start at 6 months or a year and be awarded every year or even every 5 years. Performance recognition is when employees are rewarded for their behavior, effort, or achievement that is above expectation and supports the organization’s mission, vision, and values. Regional data for the amount of bonus and number of DSPs who received a bonus were reported by a small number of organizations, so caution is required when interpreting the results about DSP bonuses.

	State	East	Middle	West
Bonus Type	%	%	%	%
Employee Referral Bonus	57	62	58	46
Hiring Bonus	22	29	19	18
Years of Service Bonus	33	43	32	18
Performance Recognition Bonus	30	38	32	9
Other Bonus	19	10	26	18

Number of organizations reporting = State (62/63), East (21), Middle (31), West (11).

% = Percent of out of the total organizations who offered the bonus.

Referral bonus

As seen in Table 3, 57% of organizations gave a referral bonus to DSPs across the state. By region, 62% of organizations provided referral bonuses in the East, 58% provided referral bonuses in the Middle, and 46% of organizations provided referral bonuses in the West. The average employee referral bonus in the state was $176. By region, the average referral bonus was $246 in the East, $151 in the Middle, and $76 in the West. For organizations who provided referral bonuses, the average number of DSPs who received referral bonuses was 13 across the state. By region, the average number of DSPs in an organization who received a referral bonus was 8 in the East, 19 in the Middle, and 6 in the West.

Hiring bonus

Throughout the state, 22% of organizations provided a hiring bonus to newly hired DSPs. By region, 29% of organizations provided hiring bonuses in the East, 19% of organizations provided hiring bonuses in the Middle, and 18% of organizations provided hiring bonuses in the West (see Table 3). The average hiring bonus in the state was $721. By region, the average hiring bonus was $883 in the East, $620 in the Middle, and $250 in the West. For organizations who provided a hiring bonus, the average number of DSPs who received a hiring bonus was 19 across the state. By region, the average number of DSPs in an organization who received a hiring bonus was 22 in the East and 17 in the Middle region. The number was not reported for the West region.

Years of service bonus

As seen in Table 3, 33% of organizations gave a bonus to DSPs for years of service across the state.  By region, 43% of organizations provided years of service bonuses in the East, 32% of organizations provided years of service bonuses in the Middle, and 18% of organizations provided years of service bonuses in the West. The average employee bonus for years of service in the state was $228. By region, the average bonus for years of service was $275 in the East and $191 in the Middle. There was no amount reported for the West region. For organizations who provided a bonus for years of service, the average number of DSPs who received a bonus for years of service was 57 across the state. By region, the average number of DSPs in an organization who received a bonus for years of service was 78 in the East, 42 in the Middle, and 5 in the West. 

Performance recognition bonus

Throughout the state, 30% of organizations gave a performance recognition bonus to DSPs. By region, 38% of organizations provided performance recognition bonuses in the East, 32% of organizations provided performance recognition bonuses in the Middle, and 9% of organizations provided recognition bonuses in the West (see Table 3). The average employee performance recognition bonus in the state was $716. By region, the average performance recognition bonus was $809 in the East, $491 in the Middle, and $2,000 in the West. For organizations who provided performance recognition bonuses, the average number of DSPs per organization who received a performance recognition bonus was 56. By region, the average number of DSPs in an organization who received a performance recognition bonus was 57 in the East, 59 in the Middle, and 1 in the West. 

Other bonuses

Across the state, 30% of organizations provided bonuses to DSPs for reasons other than employee referral, hiring, years of service, or performance recognition bonuses. By region, 10% of organizations provided a bonus for other reasons in the East, 26% of organizations provided a bonus for other reasons in the Middle, and 18% of organizations provided a bonus for other reasons in the West (see Table 3). Organizations were asked to specify the other reasons they provided bonuses. The other reasons they provided were:

• 2% across the board bonus given to everyone
• Attendance
• Thanksgiving and/or Christmas bonus
• Non-reoccurring funds from DIDD
• Staff appreciation, and
• Year-end bonus.

The average bonus for reasons other than employee referral, hiring, years of service, or performance recognition bonuses in the state was $625. By region, the average bonus for other reasons was $425 in the East, $368 in the Middle, and $1,850 in the West. For organizations who provided a bonus for other reasons, the average number of DSPs who received a bonus for other reasons was 126 across the state. By region, the average number of DSPs in an organization who received a bonus for other reasons was 323 in the East, 90 in the Middle, and 25 in the West.

DSP Work Hours and Overtime

Organizations were asked to respond to questions about the number of hours DSPs worked per week and the number of hours of overtime DSPs are working on average. Overtime is a significant cost in the long-term services and support system. Many DSPs rely on overtime to earn a livable wage. In a study of DSPs in Minnesota, 68% of DSPs reported that they would work more hours or overtime if they were available at their primary employer (Hewitt et al., 2019; Test et al., 2003). Nearly 30% of DSPs in that survey worked a second job. Depending on settings where services are provided (e.g., residential), high DSP vacancy rates may necessitate that DSPs work overtime hours. Reporting the number of hours 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.

DSP Work Hours

Organizations reported the average number of hours, including overtime, that DSPs worked per week.  Only those organizations that could differentiate between part-time and full-time DSPs provided the average number of hours for both part-time and full-time DSPs. The organizations who could not differentiate between part-time and full-time DSPs provided the average number of hours for all of their DSPs combined. The average number of hours DSPs worked per week is summarized in Table 4.

	State		East		Middle		West
Work Hours	N	Average	N	Average	N	Average	N	Average
All DSPs	46	42	16	48	23	40	7	34
Part-Time	19	25	6	31	9	25	4	17
Full-Time	21	45	7	50	10	43	4	39

N = The number of organizations answering each question.

Average = The average number of hours worked by DSPs weekly.

Across all organizations throughout the state, DSPs worked an average of 42 (range 18 to 80) hours per week. For organizations who could differentiate between part-time and full-time employees, part-time DSPs worked an average of 25 (range 4 to 75) hours per week and full-time DSPs worked an average of 45 (range 20 to 86) hours per week. 

• In the East region across all organizations, DSPs worked an average of 48 (range 30 to 80) hours per week. For organizations who could differentiate between part-time and full-time employees, part-time DSPs worked an average of 31 (range 16 to 75) hours per week and full-time DSPs worked an average of 50 (range 37 to 86) hours per week.
• In the Middle region across all organizations, DSPs worked an average of 40 (range 22 to 60) hours per week. For organizations who could differentiate between part-time and full-time employees, part-time DSPs worked an average of 25 (range 15 to 35) hours per week and full-time DSPs worked an average of 43 (range 30 to 50) hours per week.
• In the West region across all organizations, DSPs worked an average of 34 (range 18 to 48) hours per week. For organizations who could differentiate between part-time and full-time employees, part-time DSPs worked an average of 17 (range 4 to 23) hours per week and full-time DSPs worked an average of 39 (range 20 to 48) hours per week.

DSP Overtime Hours

Organizations reported overtime hours paid to DSPs in the last 30 days. Figure 9 indicates the overall number of overtime hours paid to DSPs in the last 30 days. Across the state, the average number of overtime hours that organizations paid out to DSPs in the last 30 days was 7,942 (range 0 to 151,506).  The total number of overtime hours paid out in the last 30 days from 53 organizations was 420,920. In the East, the average number of overtime hours paid out was 7,301 (range 0 to 41,264) with a total of 131,425 overtime hours paid to DSPs. In the Middle, the average number of overtime hours paid out was 2,924 (range 0 to 13,115) with a total of 81,862 overtime hours paid to DSPs. In the West, the average number of overtime hours paid out was 29,662 (range 16 to 151,506) with a total of 207,633 overtime hours paid to DSPs.

DSP Retention

DSP retention is addressed in this survey by considering turnover (crude separation), vacancy rates, 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.

DSP Turnover

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

Measuring Turnover

The formula used to compute turnover (annual crude separation rate) was calculated using 3 variables: the number of DSPs who left in the past year, the total number of DSPs employed, and the number of DSP vacancies. The crude separation rate was defined as:

Across the state, annual turnover for full-time DSPs in calendar year 2020 was 53%. Turnover among part-time DSPs was 87%. The overall DSP (both full-time and part-time) annual turnover rate was 63%.

• In the East, the average turnover rate among full-time DSPs was 47%. Among part-time DSPs, the average turnover rate was 26%. The average turnover rate among all DSPs in the region was 55%.
• In the Middle, the average turnover rate among full-time DSPs was 62%. Among part-time DSPs, the average turnover rate was 115%. The average turnover rate for all DSPs in the Middle region was 73%.
• In the West, the average turnover rate among full-time DSPs was 41%. The average turnover rate among part-time DSPs was 73%. The average turnover rate among all DSPs in the West region was 47%.

The rates for overall turnover within the first year of employment  are shown in Figure 10.

DSP Separations Within 0 to 6 and 6 to 12 Months

Early separation within the first 6 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). It is also detrimental for people who receive DSP supports when there is little time to develop a professional relationship with a DSP before a new one is hired (Friedman, 2018). Every DSP who leaves the organization requires an existing employee to backfill the vacated shifts while a new DSP is hired and trained. Data were gathered to show the percent of DSPs who left within their first year of employment.

Within 0 to 6 Months of Hire

The DSP separation rate within 0 to 6 months of hire was calculated using 2 variables: the number of DSPs who left in the past year and the total number of DSPs who left within 0 to 6 months of being hired. The 0 to 6 month separation rate was defined as:

In the state, the average DSP separation rate within 0 to 6 months of hire was 47% across all DSPs, 53% for part-time DSPs, and 43% for full-time DSPs. In the East region, the average DSP separation rate within 0 to 6 months of hire was 42% across all DSPs, 36% for part-time DSPs, and 43% for full-time DSPs. In the Middle region, the average DSP separation rate within 0 to 6 months of hire was 48% across all DSPs, 59% for part-time DSPs, and 38% for full-time DSPs. In the West region, the average DSP separation rate within 0 to 6 months of hire was 52% across all DSPs and 58% for both part-time and full-time DSPs.

Within 6 to 12 Months of Hire

The DSP separation rate within 6 to 12 months of hire was calculated using 2 variables: the number of DSPs who left in the last year and the total number of DSPs who left within 6 to 12 months of being hired. The 6 to 12 month separation rate was defined as:

In the state, the average DSP separation rate within 6 to 12 months of hire was 22% across all DSPs, 32% for part-time DSPs, and 24% for full-time DSPs. In the East region, the average DSP separation rate within 6 to 12 months of hire was 21% across all DSPs, 41% for part-time DSPs, and 22% for full-time DSPs. In the Middle region, the average DSP separation rate within 6 to 12 months of hire was 22% across all DSPs, 25% for part-time DSPs, and 22% for full-time DSPs. In the West region, the average DSP separation rate within 6 to 12 months of hire was 28% across all DSPs, 42% for part-time DSPs, and 37% for full-time DSPs.

DSP Vacancy Rate

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

Measuring Vacancy Rate

The DSP vacancy rate was calculated for this report using 2 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 11. The average vacancy rate among all DSP positions was 19%. The average vacancy rate for part-time positions was 36%, and the average vacancy rate for full-time positions was 21%.

In the East, the average vacancy rate among full-time DSPs was 22%. The average part-time DSP vacancy rate was 29%. The average vacancy rate among all DSP positions was 19%. In the Middle, the average vacancy rate among full-time DSPs was 19%. The average part-time DSP vacancy rate was 38%. The average vacancy rate among all DSP positions was 18%. In the West, the average vacancy rate among full-time DSP positions was 28%. The average vacancy rate among part-time DSP position in the West region was 40%. The average vacancy rate among all DSP positions was 17%.

Reasons DSPs Give for Leaving Their Positions

Most of the organizations in the state (93%) track reasons that DSPs give for leaving their position.  Organizations were asked to select the top three reasons that DSPs give for leaving their position. Table 5 shows the percentage of providers in the state and regions that selected each reason as one of their top three. The table is ordered from greatest to least percentage of organizations in the state.

Reason for Leaving	State	East	Middle	West
Found another job at another company	72%	57%	85%	67%
No call/No show	70%	67%	67%	89%
Pay too low, needed better pay	58%	52%	59%	67%
Was terminated/fired	30%	43%	22%	22%
Not a good fit for the type of work	18%	14%	22%	11%
Had too little or poor quality time from supervisors	4%	10%	0%	0%
Advanced to a new position within the company in a different service	2%	0%	4%	0%
Could not get along with co-workers	2%	5%	0%	0%
Training/support was inadequate	2%	0%	4%	0%
Not recognized for work he/she did	2%	0%	4%	0%
Other	23%	29%	19%	22%

Note: 57 organizations reported data for the state, 21 for East, 27 for Middle, and 9 for West

Organizations in the state selected “found another job at another company” (72%) as the reason most commonly given for DSPs leaving their position. “No call/No show” (70%) was the second most common reason given, and “Pay too low and needed better pay” (58%) was the third most commonly given reason. “Termination or being fired” (30%), “not a good fit for the type of work” (18%), “having too little or poor quality time with their supervisor” (4%), “advanced to a new position within the company in a different service” (2%), “could not get along with co-workers” (2%), “training/support was inadequate” (2%), and “not recognized for the work he/she did” (2%) were also selected by some organizations.  There were some regional differences in percentages of organizations that selected the reasons, but the largest percentage of providers selected the same top four reasons in each of the three regions and the state.

Nearly one-quarter (23%) of organizations selected “other” as a top reason that DSPs gave for leaving their position. Organizations had the opportunity to write in the “other” reason, which included the following:

• Background check did not meet hiring requirements
• COVID-19
• Most quit to file for the extra money with unemployment
• Moving out of state or to another county
• Personal reasons/Voluntary
• Retired, and
• Would not complete Relias.

DSP Benefits

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

Organizations reported if they offered paid time off (not differentiating between sick leave and paid vacation), sick leave, paid vacation, and health benefits. Organizations who could differentiate between part-time and full-time were asked to provide their paid time off, sick leave, paid vacation, and health insurance information for both part-time and full-time DSPs. Organizations who were unable to differentiate between part-time and full-time were asked to report for all of their DSPs combined. Monetary amounts paid out for paid leave options were reported by a small number of organizations, so interpret with caution.

	Paid Time Off (PTO)		Paid Sick Leave		Paid Vacation
	N	%	N	%	N	%
All DSPs	15	40%	9	22%	9	33%
Part-Time	46	4%	16	6%	14	0%
Full-time	47	66%	16	31%	15	27%

N = The number of organizations answering each question.

% = The percent organizations out of the total who offered paid leave.

Note: Data for All DSPs combined were provided only by those organizations who were unable to differentiate between part-time and full-time DSPs or who did not answer the question about capacity to break their DSP data down in this manner.

Paid Time Off

Sixty-six percent of the organizations who could differentiate between part-time and full-time DSPs offered paid time off (PTO) to full-time DSPs. This means these organizations did not distinguish between sick and vacation time. On average, the organizations who offered PTO to full-time DSPs spent $108,278 on this benefit. Only 4% of organizations offered PTO (not differentiating between sick and vacation time) to part-time DSPs (see Table 6). Not enough organizations answered to compute an average for how much was spent on PTO offered to part-time DSPs. Forty percent of the organizations who could not differentiate between part-time and full-time DSPs offered PTO to all of their DSPs. On average, the organizations who could not differentiate between part-time and full-time DSPs spent, on average, $35,037 on this benefit. 

Paid Sick Leave

As seen in Table 6, 31% of organizations who could differentiate between part-time and full-time DSPs offered paid sick leave to full-time DSPs. Of the organizations reporting, the average amount spent on paid sick leave across full-time DSPs in 2020 was $145,744. Only 6% of organizations offered paid sick leave to part-time DSPs. Not enough organizations answered to compute an average for how much was spent on paid sick leave for part-time DSPs. Twenty-two percent of the organizations who could not differentiate between part-time and full-time DSPs offered paid sick leave to all of their DSPs. Not enough organizations answered to compute an average for how much was spent on paid sick leave for part-time or full-time DSPs combined. 

Paid Vacation Time

Twenty-seven percent of organizations who could differentiate between part-time and full-time DSPs offered paid vacation to their full-time DSPs. Of the organizations reporting, the average amount spent on paid vacation across full-time DSPs in 2020 was $22,506. No organization offered paid vacation to part-time DSPs (see Table 6). For organizations who could not differentiate between part-time and full-time DSPs, 33% offered paid vacation to all of their DSPs. An average amount of $20,700 was spent on paid vacation time.

Health Insurance

Across the state, 83% of the 47 organizations who could differentiate between part-time and full-time DSPs offered health insurance to their full-time DSPs, and only 17% offered health insurance to part-time DSPs. Sixty percent of the 15 organizations who could not differentiate between part-time and full-time DSPs offered health insurance to all of their DSPs. The average minimum number of hours a DSPs had to work per week to be eligible for health insurance was 31. The average percent of DSPs who were enrolled in health insurance through their organization was 35%.

Insurance Coverage	# of  Organizations	Organization Cost	# of Organizations	DSP Cost
Individual	38	$525	36	$155
Two-Person	32	$454	29	$629
Family	34	$554	33	$929

N = The number of organizations answering each question.

Average Cost = The average amount paid for the coverage option.

Organizations reported the average cost per month of health insurance for individual, two-person, and family coverage for both the organization and the DSP. As seen in Table 7, organizations throughout the state paid an average of $525 per DSP for health insurance premium contributions each month for individual coverage. The average cost for two-person coverage was $454, and the average cost for family coverage was $554 per DSP. The average employee’s contribution for monthly health insurance premium contribution for individual coverage was $155. The monthly cost increased to $629 for two-person coverage and $929 for family coverage.

Frontline Supervisors

A frontline supervisor (FLS) is an employee whose primary responsibility is the supervision of 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 DSPs, rather the organization views their role as guiding and directing the work of DSPs more than 50% of their time. 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).

FLS 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.

Figure 12 shows the average FLS starting, average, and highest salaries for all DSPs. The average starting salary for FLSs across the state was $31,522 (range $16,640 to $45,000). In each region, the average starting salary for FLSs was $31,871 (range $19,720 to $40,000) in the East, $32,430 (range $21,320 to $45,000) in the Middle, and $27,615 (range $16,640 to $41,000) in the West. 

The overall average salary for FLSs across the state was $34,024 (range $21,320 to $46,461). In each region, the average salary for FLSs was $33,976 (range $23,000 to $40,000) in the East, $34,780 (range $21,320 to $45,000) in the Middle, and $31,391 (range $24,190 to $46,461) in the West. 

The average highest salary for FLSs across the state was $38,731 (range $23,000 to $66,953). In each region, the average highest salary for FLSs was $38,581 (range $23,000 to $66,953) in the East, $39,333 (range $22,880 to $29,120) in the Middle, and $36,869 (range $23,000 to $50,000) in the West.

FLS Retention

FLS turnover is a key issue nationwide for stabilizing the direct support workforce. Turnover, early separations, and vacancy for all FLSs were computed for this report. FLS turnover and early separation data are shown in Figure 13.

FLS Turnover

FLS annual turnover was calculated using the annual crude separation rate which uses 3 variables: the number of FLSs who left in the last year, the total number of FLSs employed, and the number of FLS vacancies.  The crude separation rate was defined as:

The average FLS turnover throughout the state was 21%. By region, the average turnover of FLSs was 18% in the East, 17% in the Middle, and 47% in the West.

FLS Separations Within 0 to 6 and 6 to 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 DSP but make less money because they are often salaried employees and not paid overtime compared to DSPs who are paid overtime and work many hours of overtime each week. Additionally, FLSs are often promoted from DSP positions and may realize they do not have the necessary skills to be an effective FLS and prefer working as a DSP. Early turnover of FLSs can be particularly distressing for 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 DSPs as higher supervisor turnover may be a predictor for higher DSP turnover.

Within 0-6 Months of Hire

FLS separation rate within 0 to 6 months of hire was calculated using 2 variables: the number of FLSs who left in the last year and the total number of FLSs who left within 0 to 6 months of being hired. The 0 to 6 month separation rate was defined as:

In the state, the average FLS separation rate within 0 to 6 months of hire was 23%. By region, the average FLS separation rate within 0 to 6 months of hire was 17% in the East, 18% in the Middle, and 43% in the West.

Within 6 to 12 Months of Hire

FLS separation rate within 6 to 12 months of hire was calculated using 2 variables: the number of FLSs who left in the last year and the total number of FLSs who left within 6 to 12 months of being hired. The 6 to 12 month separation rate was defined as:

Throughout the state, the average FLS separation rate within 6 to 12 months of hire was 29%. By region, the average FLS separation rate within 6 to 12 months of hire was 22% in the East, 19% in the Middle, and 57% in the West.

FLS Vacancy Rate

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

As seen in Figure 14, the average FLS vacancy rate was 13% across the state. By region, the average FLS vacancy rate was 17% in the East, 12% in the Middle, and 30% in the West.

Service Areas

This section of the report summarizes program participation within services, including (1) ECF CHOICES, (2) DIDD Waiver service, (3) Vocational Rehabilitation, and (4) CHOICES (Non-ECF CHOICES). Within each service area were multiple service types for a total of 15 programs across the four service areas. Organizations were asked to identify which services they provided out of these 15 service types.

Service Types

All organizations provided at least two service types. Twelve percent of organizations provided two or three service types, 15% provided four or five service types, and 28% provided between six and 10 service types. Forty percent of organizations provided between 11 and 14 service types. Five percent of organizations provided all 15 service types.

ECF CHOICES Qualified Job Developer

	# of Organizations	All DSPs
% Provide Service	62	52%
Average # DSPs per Organization	17	11
Starting Wages	12	$11.18
Average Wages	11	$11.92
Highest Wages	10	$13.97
Total Overtime Hours Last 30 Days	14	129

As seen in Table 8, 52% of organizations across the state provided ECF CHOICES Employment Services Requiring a Qualified Job Developer. In 2020, organizations employed an average of 11 DSPs (range 0 to 146) for this service. There was a total of 179 DSPs who provided this service across 17 organizations.  For DSPs who provided Employment Services Requiring a Qualified Job Developer, the average starting wage was $11.18, the average wage overall was $11.92, and the average highest wage was $13.97. On average, there were 9 (range 0 to 109) overtime hours paid to DSPs in the last 30 days. There was a total of 129 overtime hours paid to DSPs in the last 30 days.

ECF CHOICES Qualified Job Coach

	# of Organizations	All DSPs
% Provide Service	62	60%
Average # DSPs per Organization	23	11
Starting Wages	20	$10.18
Average Wages	17	$11.20
Highest Wages	16	$12.56
Total Overtime Hours Last 30 Days	17	466

Sixty percent of organizations across the state provided ECF CHOICES Employment Services Requiring a Qualified Job Coach. In 2020, organizations employed an average of 11 DSPs (range 0 to 146) for this service. There was a total of 261 DSPs who provided this service across 23 organizations. For DSPs who provided Employment Services Requiring a Qualified Job Coach, the average starting wage was $10.18, the average wage overall was $11.20, and the average highest wage was $12.56. The average overtime hours paid to DSPs in the last 30 days was 27 (range 0 to 262). In the last 30 days, there was a total of 466 overtime hours paid to DSPs (see Table 9).

ECF CHOICES Community Integration Support Services/Independent Living Skills Training

Seventy percent of organizations provided ECF CHOICES Community Integration Support Services and/or Independent Living Skills Training to one or more ECF CHOICES members. Table 10 summarizes information about DSPs providing these services. 

	# of Organizations	All DSPs
% Provide Service	61	62%
Average # DSPs per Organization	25	13
Starting Wages	20	$10.34
Average Wages	17	$11.30
Highest Wages	17	$12.51
Total Overtime Hours Last 30 Days	17	1,105

As seen in Table 10, 62% of organizations across the state provided ECF CHOICES Community Integration Support Services/Independent Living Skills Training. In 2020, organizations employed an average of 13 DSPs (range 0 to 146) for this service. There was a total of 333 DSPs who provided this service across 25 organizations. For DSPs who provided Community Integration Support Services/Independent Living Skills Training, the average starting wage was $10.34, the average wage overall was $11.30, and the average highest wage was $12.51. The average overtime hours paid to DSPs in the last 30 days was 65 (range 0 to 903). In the last 30 days, there was a total of 1,105 overtime hours paid to DSPs.

ECF CHOICES Community Living Supports (CLS)

	# of Organizations	All DSPs
% Provide Service	62	74%
Average # DSPs per Organization	28	32
Starting Wages	26	$10.06
Average Wages	23	$11.12
Highest Wages	23	$12.59
Total Overtime Hours Last 30 Days	19	5,339

Seventy-four percent of organizations across the state provided ECF CHOICES Community Living Supports. In 2020, organizations employed an average of 32 DSPs (range 0 to 303) for this service. There was a total of 902 DSPs who provided this service across 28 organizations. For DSPs who provided Community Living Supports, the average starting wage was $10.06, the average wage overall was $11.12, and the average highest wage was $12.59. The average overtime hours paid to DSPs in the last 30 days was 281 (range 0 to 2,315). In the last 30 days, there was a total of 5,339 overtime hours paid to DSPs (see Table 11).

ECF CHOICES Personal Assistance and/or Supportive Home Care

	# of Organizations	All DSPs
% Provide Service	62	63%
Average # DSPs per Organization	27	10
Starting Wages	20	$10.38
Average Wages	17	$11.21
Highest Wages	16	$12.75
Total Overtime Hours Last 30 Days	17	391

As seen in Table 12, 63% of organizations across the state provided ECF CHOICES Personal Assistance and/or Supportive Home Care. In 2020, organizations employed an average of 10 DSPs (range 0 to 130) for this service. There was a total of 262 DSPs who provided this service across 27 organizations. For DSPs who provided Personal Assistance and/or Supportive Home Care, the average starting wage was $10.38, the average wage overall was $11.21, and the average highest wage was $12.75. The average overtime hours paid to DSPs in the last 30 days was 23 (range 0 to 219). In the last 30 days, there was a total of 391 overtime hours paid to DSPs.

DIDD Waiver 1915c Employment Supports

	# of Organizations	All DSPs
% Provide Service	61	69%
Average # DSPs per Organization	26	29
Starting Wages	22	$10.02
Average Wages	19	$10.92
Highest Wages	18	$12.43
Total Overtime Hours Last 30 Days	17	5,959

Sixty-nine percent of organizations across the state provided DIDD Waiver 1915c Employment Supports.  In 2020, organizations employed an average of 29 DSPs (range 0 to 203) for this service. There was a total of 744 DSPs who provided this service across 26 organizations. For DSPs who provided DIDD Waiver 1915c Employment Supports, the average starting wage was $10.02, the average wage overall was $10.92, and the average highest wage was $12.43. The average overtime hours paid to DSPs in the last 30 days was 351 (range 0 to 5,657). In the last 30 days, there was a total of 5,959 overtime hours paid to DSPs across 17 organizations (see Table 13).

DIDD Waiver 1915c Residential/Supported Living Services

	# of Organizations	All DSPs
% Provide Service	62	77%
Average # DSPs per Organization	31	96
Starting Wages	29	$10.09
Average Wages	25	$11.16
Highest Wages	26	$13.31
Total Overtime Hours Last 30 Days	23	90,045

As seen in Table 14, 77% of organizations across the state provided DIDD Waiver 1915c Residential/Supported Living Services. In 2020, organizations employed an average of 96 DSPs (range 4 to 373) for this service. There was a total of 2,990 DSPs who provided this service across 31 organizations. For DSPs who provided DIDD Waiver 1915c Residential/Supported Living Services, the average starting wage was $10.09, the average wage overall was $11.16, and the average highest wage was $13.31. The average overtime hours paid to DSPs in the last 30 days was 3,915 (range 0 to 41,000). In the last 30 days, there was a total of 90,045 overtime hours paid to DSPs.

DIDD Waiver 1915c Personal Assistance Services

	# of Organizations	All DSPs
% Provide Service	62	73%
Average # DSPs per Organization	27	30
Starting Wages	27	$9.99
Average Wages	24	$10.72
Highest Wages	23	$12.07
Total Overtime Hours Last 30 Days	19	7,838

Seventy-three percent of organizations across the state provided DIDD Waiver 1915c Personal Assistance Services. In 2020, organizations employed an average of 30 DSPs (range 0 to 203) for this service. There was a total of 818 DSPs who provided this service across 27 organizations. For DSPs who provided DIDD Waiver 1915c Personal Assistance Services, the average starting wage was $9.99, the average wage overall was $10.72, and the average highest wage was $12.07. The average overtime hours paid to DSPs in the last 30 days was 413 (range 0 to 5,657). In the last 30 days, there was a total of 7,838 overtime hours paid to DSPs (see Table 15).

DIDD Waiver 1915c Community Based Services

	# of Organizations	All DSPs
% Provide Service	62	79%
Average # DSPs per Organization	28	66
Starting Wages	30	$9.99
Average Wages	26	$11.08
Highest Wages	26	$12.83
Total Overtime Hours Last 30 Days	20	7,815

As seen in Table 16, 79% of organizations across the state provided DIDD Waiver 1915c Community Based Services. In 2020, organizations employed an average of 66 DSPs (range 0 to 303) for this service.  There was a total of 1,844 DSPs who provided this service across 28 organizations. For DSPs who provided DIDD Waiver 1915c Community Based Services, the average starting wage was $9.99, the average wage overall was $11.08, and the average highest wage was $12.83. The average overtime hours paid to DSPs in the last 30 days was 391 (range 0 to 5,657). In the last 30 days, there was a total of 7,815 overtime hours paid to DSPs.

DIDD Waiver 1915c Facility Based Services

	# of Organizations	All DSPs
% Provide Service	61	34%
Average # DSPs per Organization	11	16
Starting Wages	12	$10.04
Average Wages	10	$11.02
Highest Wages	10	$12.51
Total Overtime Hours Last 30 Days	7	0

As seen in Table 17, 34% of organizations across the state provided DIDD Waiver 1915c Facility Based Services. In 2020, organizations employed an average of 16 DSPs (range 1 to 130) for this service. There was a total of 178 DSPs who provided this service across 11 organizations. For DSPs who provided DIDD Waiver 1915c Facility Based Services, the average starting wage was $10.04, the average wage overall was $11.02, and the average highest wage was $12.51. There were no overtime hours paid to DSPs in the last 30 days for this service.

Vocational Rehabilitation: Qualified Employment Specialist

	# of Organizations	All DSPs
% Provide Service	61	49%
Average # DSPs per Organization	15	12
Starting Wages	11	$10.93
Average Wages	11	$11.76
Highest Wages	11	$13.60
Total Overtime Hours Last 30 Days	10	0

Forty-nine percent of organizations across the state provided Vocational Rehabilitation Employment Services Requiring a VR-Qualified Employment Specialist. In 2020, organizations employed an average of 12 DSPs (range 0 to 146) for this service. There was a total of 180 DSPs who provided this service across 15 organizations. For DSPs who provided Vocational Rehabilitation Employment Services Requiring a VR-Qualified Employment Specialist, the average starting wage was $10.93, the average wage overall was $11.76, and the average highest wage was $13.60. There were no overtime hours paid to DSPs in the last 30 days for this service (see Table 18).

Vocational Rehabilitation Qualified Job Coach

	# of Organizations	All DSPs
% Provide Service	61	48%
Average # DSPs per Organization	17	12
Starting Wages	16	$10.04
Average Wages	14	$11.04
Highest Wages	13	$12.67
Total Overtime Hours Last 30 Days	13	24

As seen in Table 19, 48% of organizations across the state provided Vocational Rehabilitation Employment Services Requiring a VR-Qualified Job Coach. In 2020, organizations employed an average of 12 DSPs (range 0 to 146) for this service. There was a total of 202 DSPs who provided this service across 17 organizations. For DSPs who provided Vocational Rehabilitation Employment Services Requiring a VR-Qualified Job Coach, the average starting wage was $10.04, the average wage overall was $11.04, and the average highest wage was $12.67. The average overtime hours paid to DSPs in the last 30 days was 2 (range 0 to 24). In the last 30 days, there was a total of 24 overtime hours paid to DSPs.

CHOICES (Non-ECF CHOICES): Personal Care Services

	# of Organizations	All DSPs
% Provide Service	62	45%
Average # DSPs per Organization	17	33
Starting Wages	17	$10.28
Average Wages	14	$10.95
Highest Wages	14	$12.22
Total Overtime Hours Last 30 Days	16	1,063

Forty-five percent of organizations across the state provided CHOICES (Non-ECF CHOICES) Personal Care Services. In 2020, organizations employed an average of 33 DSPs (range 0 to 130) for this service. There was a total of 563 DSPs who provided this service across 17 organizations. For DSPs who provided CHOICES (Non-ECF CHOICES) Personal Care Services, the average starting wage was $10.28, the average wage overall was $10.95, and the average highest wage was $12.22. The average overtime hours paid to DSPs in the last 30 days was 66 (range 0 to 597). In the last 30 days, there was a total of 1,063 overtime hours paid to DSPs (see Table 20).

CHOICES (Non-ECF CHOICES): Attendant Care Services

	# of Organizations	All DSPs
% Provide Service	61	43%
Average # DSPs per Organization	16	35
Starting Wages	16	$10.30
Average Wages	14	$10.87
Highest Wages	14	$12.08
Total Overtime Hours Last 30 Days	14	320

As seen in Table 21, 43% of organizations across the state provided CHOICES (Non-ECF CHOICES) Attendant Care Services. In 2020, organizations employed an average of 35 DSPs (range 0 to 130) for this service. There was a total of 555 DSPs who provided this service across 16 organizations. For DSPs who provided CHOICES (Non-ECF CHOICES) Attendant Care Services, the average starting wage was $10.30, the average wage overall was $10.87, and the average highest wage was $12.08. The average overtime hours paid to DSPs in the last 30 days was 23 (range 0 to 120). In the last 30 days, there was a total of 320 overtime hours paid to DSPs.

CHOICES (non-ECF CHOICES): Community Living Supports

	# of Organizations	All DSPs
% Provide Service	62	52%
Average # DSPs per Organization	18	52
Starting Wages	19	$10.09
Average Wages	16	$10.98
Highest Wages	17	$12.38
Total Overtime Hours Last 30 Days	9	9,536

Fifty-two percent of organizations across the state provided CHOICES (Non-ECF CHOICES) Community Living Supports. In 2020, organizations employed an average of 52 DSPs (range 0 to 303) for this service. There was a total of 944 DSPs who provided this service across 18 organizations. For DSPs who provided CHOICES (Non-ECF CHOICES) Community Living Supports, the average starting wage was $10.09, the average wage overall was $10.98, and the average highest wage was $12.38. The average overtime hours paid to DSPs in the last 30 days was 1,060 (range 0 to 9,536). In the last 30 days, there was a total of 9,536 overtime hours paid to DSPs (see Table 22).

Revenue & Worker’s Compensation Costs

Statewide, the average of the total annual revenue per organization was $18,973,021 (range $156,000 to $473,961,881). By region, the average total annual revenue was $40,943,719 (range $156,000 to $473,961,881) in the East, $6,710,078 (range $400,000 to $40,000,000) in the Middle, and $11,923,052 (range $209,000 to $28,911,264) in the West. On average, 92% of organizations’ total dollars statewide were authorized for services, and an average of 96% of the organizations’ total dollars for services were actually billed (i.e., authorized expenses billed). In the East, an average of 91% of total dollars were authorized for services, and 94% of the total dollars for services were actually billed. In the Middle, an average of 92% of total dollars were authorized for services, and 97% of the total dollars for services were actually billed. In the West, an average of 95% of total dollars were authorized for services, and 97% of the total dollars for services were actually billed.

Revenue from ECF CHOICES

Across the state, an average of 45% of overall revenue derived from ECF CHOICES rates was directed toward part-time and full-time wages for DSPs. By region, 50% of revenue from ECF CHOICES rates were directed toward DSP wages in the East, 47% in the Middle, and 21% in the West. Statewide, an average of 15% of organizations’ overall revenue derived from ECF CHOICES rates was used for DSP worker’s compensation. By region, 9% of overall revenue from ECF CHOICES rates was used for DSP worker’s compensation in the East, 18% in the Middle, and 24% in the West.

COVID-19 Experiences

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

Organizations were asked to select all of the experiences their organization had undergone in the delivery of services due to the pandemic during 2020.

Experiences Had During Covid-19

Experiences	State	East	Middle	West
Staff were relocated (temporarily or permanently) to another setting	52%	59%	58%	22%
Staff lived in residence(s) to slow COVID-19 spread	31%	41%	23%	33%
Facility/organization closed due to government mandate	25%	18%	19%	56%
Staff were furloughed or laid off	23%	12%	31%	22%
Staff hours were cut	15%	18%	15%	11%
Staff positions were eliminated	8%	0%	15%	0%
Other	35%	35%	39%	22%

Note: 52 organizations reported data for the state, 17 for East, 26 for Middle, 9 for West

As seen in Table 23, organizations in the state selected “staff were relocated (temporarily or permanently) to another setting” (52%) as the experience most commonly had due to Covid-19. “Staff lived in residence(s) to slow COVID-19 spread)” (31%) was the second most common experience, and “facility/organization closed due to government mandate” (25%) was the third most commonly given experience. “Staff were furloughed or laid off” (23%), “staff hours were cut” (15%), and “staff positions were eliminated” (8%) were also selected by some organizations. There were some regional differences in percentages of organizations that selected the experiences, but the largest percentage of providers selected the same top four experiences in each of the three regions and the state.

Over one-third (35%) of organizations selected “other” as a top experience during COVID-19.  Organizations had the opportunity to write in the “other” experience, which included the following:

• No change
• Center closed to public or day services centers closed
• Staff relocated to other locations
• Staff had increased work hours due to Covid
• Staff quit to file for extra unemployment money, and
• Clients declined services or put them on hold due to fear of DSP worker coming into their home.

Turnover and Hiring Practices During the COVID-19 Pandemic

When asked about whether they were short-staffed as a result of the COVID-19 pandemic, 87% of organizations said they were more short-staffed than before the COVID-19 pandemic. 

87% of organizations said they were more short-staffed than before the COVID-19 pandemic.

With staff shortages and additional stressors caused by staff leaving their positions due to the pandemic, nearly three-quarters of organizations (72%) reported that new staff had been hired during the COVID-19 pandemic. When new staff were hired because of the pandemic, 26% of the organizations said new staff received typical orientation and preservice training, 64% said they received the typical orientation and preservice training as well as safety training related to the pandemic, and 4% said that typical orientation and preservice training were not provided.

Salary Augmentation for Direct Support Professionals

Organizations were asked if DSPs were paid more during the COVID-19 pandemic (e.g., essential worker augmentation or COVID-19 bonus). Sixty percent of organizations paid all of their DSPs more during the COVID-19 pandemic through salary augmentation. The amount of the wage increase for DSPs is depicted in Figure 15. Of the 60% who offered a salary augmentation, 20% gave an increase of $0.01 to $1.00 per hour, 18% gave $1.01 to $2.00 per hour, 3% gave $2.01 to $3.00 per hour, 12% gave $3.01 or more per hour, and 47% gave a lump sum bonus.

One-hundred percent of organizations who gave a wage increase due to COVID-19 gave it to all of their DSPs. Wage increases started in varying months of 2020 with 13% in March, 27% in April, 17% in May, 27% in June, 10% in July, 3% in September, and 3% in November. Eighty-seven percent of organizations reported that the hourly wage increase from COVID-19 has an end date.

COVID-19 Infections & Deaths

Organizations were asked about COVID-19 infections and deaths among their staff and the people whom they serve. For staff, the average percentage of those infected by Covid-19 across the state was 13% (range 0% to 50%). In each region, the average percentage of Covid-19 infections among staff was 16% (range 0% to 50%) in the East, 11% (range 0% to 29%) in the Middle, and 12% (range 0% to 33%) in the West. The percentage of deaths due to Covid-19 among staff was <1%, on average, for the state and across regions.

For people served the average percentage of those infected by Covid-19 across the state was 12% (range 0% to 69%). In each region, the average percentage of Covid-19 infections was 11% (range 0% to 32%) in the East, 11% (range 0% to 50%) in the Middle, and 16% (range 0% to 69%) in the West. The percentage of deaths due to Covid-19 among people served was 1%, on average, for the state and across regions.

Change Over Time

There were 33 organizations that participated in years one, two and three of the Employment and Community First CHOICES survey. A series of repeated measures Analysis of Covariance (ANCOVAS) were conducted to examine whether turnover (sometimes referred to as crude separation rate), vacancy rates, and DSP hourly wages and FLS salaries (starting, average, and highest) changed from year one to year three. Two additional variables representing group and individual participation in the intervention activities were also included in the analyses. The assumption at the beginning of the project was that after the intervention, turnover and vacancy rates would slightly decrease and wages would slightly increase. What wasn’t expected was the COVID-19 pandemic which affected organization functioning, specifically their staffing.

There were several issues that make the interpretation of results difficult. First, the underlying assumption of a study looking at change over time is that conditions remain relatively the same. One of the basic assumptions is that the measurement instrument remains consistent across time points. After year one, the survey was reduced in length and a few new items were added, which is not uncommon. However, the survey was also substantially reformatted. The format and order of the items changed and the overall format of the survey was changed. Second, the intervention component varied for each of the two cohorts in order to accommodate unexpected effects of the COVID 19 pandemic. In year one, the intervention began with a two-day “Understanding Your Data” in-person training in September 2019, with individual consultations beginning in November 2019 for organizations who were part of cohort one. Not all cohort one organizations had their 1st individual consultation before the end of 2019. In cohort one, key training on workforce interventions occurred through webinars which did not begin until January 2020. During year two, due to COVID19 restrictions, the intervention for organizations participating as part of cohort two “Understanding Your Data” training was modified from a 2-day in-person training to a series of eight training sessions via Zoom provided during the months of October, November, and December 2020. The individual consultation did not begin until January 2021. Additionally, one key intervention planned for this project was the implementation of the QuILTSS competency based training program with related incentives. For many reasons this intervention was not used as a part of the overall project intervention. Perhaps the most important issue was experiencing the COVID-19 pandemic during the year three data period. The pandemic affected organization functioning and more specifically their staffing.

Therefore, results cannot be directly connected to the interventions used. Significant increases or decreases may be due to the intervention, but they also may be due to other compounding factors such as the change in survey format, or more likely the COVID-19 pandemic, which changed the way business was conducted which directly affected staffing. Given the number of variables we could not control for, we cannot state with certainty which specific interventions resulted in change over time.       

Variables examined for change over time included DSP annual turnover, DSP early turnover 0 to 6 months, DSP turnover 6 to 12 months, DSP vacancy rate, and DSP hourly wages (starting, annual, and highest). Analyses were also done for FLS; however, instead of hourly wages, FLS were evaluated on salary (starting, annual, and highest). Lastly, sample sizes were too small to do regional comparisons.

DSP Retention Rates

Four measures of retention were computed and compared over time for DSPs. These included: annual turnover (sometimes referred to as crude separation rate), early turnover within 0 to 6 months of hire,  turnover within 6 to 12 months of hire, and vacancy rate.

DSP Annual Turnover

Annual DSP turnover tells the percentage of DSPs who left the organization (turned over) in the last year out of all of the DSP positions. As seen in Figure 16, for all DSPs, the average annual turnover was consistent between 2018 (52%) and 2019 (50%) but increased in 2020 (57%). For full-time DSPs, the average annual turnover decreased over time from 2018 (50%) to 2019 (40%) and 2020 (41%). For part-time DSPs, the average annual turnover increased from 45% in 2018 to 52% in both 2019 and 2020. 

Note: 27 organizations reported for All DSPs, 13 for Full-time DSPs, and 10 for Part-time DSPs.

DSP Early Turnover (0 to 6 months)

Early DSP turnover questions were added to the year two survey so there are only two data points to compare. Early DSP turnover within 0 to 6 months of hire tells the percentage of DSPs who left their position within the first 6 months of starting the job.

As seen in Figure 17, for all DSPs, the average early turnover within 0 to 6 months of hire decreased from 2019 (51%) to 2020 (45%). For full-time DSPs, the average early turnover within 0 to 6 months of hire was similar from 2019 (39%) to 2020 (40%). For part-time DSPs, the average early turnover decreased from 60% in 2019 to 53% in 2020. 

Note: 30 organizations reported for All DSPs, 13 for Full-time DSPs, and 12 for Part-time DSPs.

DSP Turnover (6 to 12 months)

DSP turnover questions were added to the year 2 survey so there were only two data points to compare. DSP turnover within 6-12 months of hire tells the percentage of DSPs who left their position within 6 to 12 months of starting the job.

As seen in Figure 18, for all DSPs, the average turnover within 6 to 12 months of hire decreased from 2019 (28%) to 2020 (25%). For full-time DSPs, the average turnover within 6-12 months of hire decreased from 2019 (38%) to 2020 (34%). For part-time DSPs, the average turnover increased from 21% in 2019 to 38% in 2020.

Note: 30 organizations reported for All DSPs, 15 for Full-time DSPs, and 10 for Part-time DSPs.

DSP Vacancy Rate

DSP vacancy rate tells the percentage of vacant positions out of all of the DSP positions.

As seen in Figure 19, for all DSPs, the average vacancy rate decreased from 14% (2018) to 12% (2019) and then increased to 20% (2020). For full-time DSPs, the average vacancy rate increased from 15% (2018) to 16% (2019) to 19% (2020). For part-time DSPs, the average vacancy rate started at 20% (2018), decreased to 14% (2019), and increased to 32% (2020).

Note: 27 organizations reported for All DSPs, 14 for Full-time DSPs, and 12 for Part-time DSPs.

DSP Hourly Wages

Organizations were asked to provide wage data for all of their DSPs, part-time DSPs, and full-time DSPs. Organizations provided data for starting hourly wages, average hourly wages, and highest hourly wages.

As seen in Figure 20, for all DSPs, the average starting hourly wage was $9.28 in 2018 and increased to $9.72 in 2019 and $10.08 in 2020. For full-time DSPs, the average starting hourly wages were $9.52 in 2018 and increased to $9.93 in 2019 and $10.02 in 2020. For part-time DSPs, the average starting hourly wage was $9.52 in 2018 and increased to $10.03 in 2019 and $10.12 in 2020. 

Note: 31 organizations reported for All DSPs, 16 for Full-time DSPs, and 16 for Part-time DSPs.

As seen in Figure 21, for all DSPs, the average hourly wage was $10.05 in 2018 and increased to $10.22 in 2019 and $10.70 in 2020. For full-time DSPs, the average hourly wages were $10.23 in 2018 and increased to $10.31 in 2019 and $10.63 in 2020. For part-time DSPs, the average hourly wage was $10.16 in 2018 and increased to $10.26 in 2019 and $10.50 in 2020.

Note: 18 organizations reported for All DSPs, 7 for Full-time DSPs, and 7 for Part-time DSPs.

As seen in Figure 22, for all DSPs, the average highest hourly wage was $12.14 in 2018 and increased to $13.08 in 2019 and $12.95 in 2020. For full-time DSPs, the average highest hourly wages were $11.87 in 2018 and increased to $11.84 in 2019 and $12.69 in 2020. For part-time DSPs, the average highest hourly wage was $10.35 in 2018 and increased to $11.40 in 2019 and $12.09 in 2020.

Note: 17 organizations reported for All DSPs, 7 for Full-time DSPs, and 7 for Part-time DSPs.

FLS Retention Rates

Frontline Supervisor items were added to the year 2 survey; therefore, there were only two points of data to compare over time. Four measures of retention were computed and compared over time for FLS. These included: annual turnover (sometimes referred to as crude separation rate), early turnover 0 to 6 months, turnover 6 to 12 months, and vacancy rate.

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

As seen in Figure 23, for FLSs, the average annual turnover was 22% in 2018 and decreased to 16% in 2019. The average early turnover within 0 to 6 months of hire decreased from 37% in 2019 to 28% in 2020. The average turnover within 6 to 12 months of hire decreased from 2019 (29%) to 2020 (26%). The average vacancy rate increased from 6% (2019) to 10% (2020).

Note: 22 organizations reported turnover, 15 reported early turnover 0-6M, 14 reported early turnover 6-12M, and 21 reported vacancy rate.

FLS Salaries

Organizations were asked to provide salary data for their FLSs. Organizations provided data for FLS starting salary, annual salary, and highest salary. As seen in Figure 24, the average FLS starting salary was $30,203 in 2019 and increased to $31,282 in 2020. The average FLS annual salary was $35,390 in 2019 and decreased to $34,776 in 2020. The average FLS highest salary was $43,908 in 2019 and decreased to $39,461 in 2020. 

Note: 28 organizations reported starting salary, 27 reported annual and highest salary.

Summary of Trends Over Time

While none of the increases or decreases in retention measures or wages and salaries were statistically significant and none of the increases or decreases can be directly attributed to involvement in training and consultation activities, there are trends worth noting, especially in light of the pandemic in 2020.

For DSPs, prior to the pandemic (2018-2019), annual turnover was trending down for All DSPs and Full-time DSPs. Early turnover within 0 to 6 months of hire went down for All DSPs and Part-time DSPs from 2019-2020. Turnover within 6 to 12 months of being hired went down for all DSPs and Full-time DSPs. DSP vacancy went down for All DSPs and Part-time DSPs prior to the pandemic (2018-2019). DSP starting and hourly wages went up at each of the three points in time (2018,2019, 2020).

For FLSs, while there was no pre-pandemic time point, between 2019 and 2020 all retention measures (turnover, early turnover within 0 to 6 months, turnover within 6 to 12 months, and vacancy rate) went down. FLS starting salaries went up at from 2019 to  2020.

Overview of Training and Consultation Activities

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

During 2020, key training and technical assistance activities included enhancing initial understanding on how to best use survey report data to identify and assess workforce challenges and select workforce solutions strategies based on an organization’s data. Additionally, ongoing technical consultation and coaching with the participating organizations was provided on selecting, and then implementing, workforce strategies. It is important to note that the onset of COVID-19 in March 2020 significantly influenced participating organizations’ availability and capacity to engage in individual consultation and coaching on their workforce development efforts. Their priorities shifted to focusing solely on responding to the health and safety of both people supported and staff during this unprecedented time. Other activities included the launch of a web-based DSP workforce toolkit and a series of 13 webinars on promising strategies in recruitment, selection, training, and retention. The webinars were initially held live with time for provider organizations to ask questions. Following the live webinar, recordings were available to participating organizations on the DSP workforce toolkit.

Additional activities aimed at building capacity for sustaining Tennessee’s workforce development efforts included developing and implementing a Workforce Coach Training program for six workforce coaches from the three Managed Care Organizations (MCOs) and four organization workforce coaches across Tennessee initiating a community of practice among participating organizations and MCOs. The workforce coach training program consisted of six biweekly training sessions with time for discussion and questions. Following the training program in September 2020, MCO and organization workforce coaches worked collaboratively with the UMN workforce consultants to implement various workforce activities through monthly coaches connect sessions and ongoing mentoring from UMN workforce consultants. These activities continued into 2021. Regional community of practice meetings were held quarterly starting in October 2020 and provided an opportunity for organizations to share problems they were having with recruiting and retaining DSPs and FLSs and discuss possible strategies to address those problems. These activities focused on building organizational and regional capacity to address workforce development needs across the state.

At the beginning of the project, these efforts were designed to provide interventions for organizations to use to improve their workforce development and outcomes that would also align with and prepare them to implement the QuILTSS Institute competency-based training and wage incentives for DSPs/FLSs. In response to COVID-19, several of the training activities were redesigned for a virtual platform that would accommodate both synchronous and asynchronous delivery methods to maximize availability of these training resources for organizations. While the QuILTSS Institute training program was not available for implementation or use throughout the course of the project, participating organizations received training and consultation to prepare them to participate in the QuILTSS Institute training program. Training and consultation on topics such as competency-based training, orientation and onboarding, professionalizing DSPs and career ladders, and employee development were intended to teach organizations best practices for implementing these strategies with fidelity and improve workforce outcomes in their organizations. During 2021, two organizations took advantage of the opportunity to participate in a new TN Apprenticeship Program for DSPs (https://quiltss.org/apprentice/ ) supported by the QuILTSS Institute and UnitedHealthcare. There are plans to expand this initiative in 2022.

The targeted sample of 114 Tennessee provider organizations completing the survey were eligible to participate in training and consultation on workforce interventions. This included an initial kick off training on understanding their workforce data, individualized monthly consultation, access to training webinars on specific workforce interventions and quarterly regional workforce community of practice sessions. Providers completing the year one (2018 data) survey who attended the initial kickoff workshop in Fall 2019 became cohort one. This two-day kickoff was in-person at a central location in the East, Middle, and West regions of Tennessee. Cohort one provider organizations started participating in workforce activities in late fall 2019.

Table 24 shows the participation for each activity in 2019, 2020 and 2021. Note, attendance below was reported by organization; however, the actual number of participants are higher because multiple employees may have attended from some participating organizations. Several organizations participated in nearly all training and consultation activities available to them.

One organization reported that one outcome of their participation in the coaches training was to create a new position in their organization to focus on implementing recruitment and retention strategies in their organization. The workforce coach from that organization was selected for this position. This is one example of the impact training and consultation on workforce interventions at an organization level.

Cohort One Organization Participation

Activity	Organizations in Attendance
Cohort 1 Kickoff Workshop Year 1 (in person)	34
Individualized Consultation	21
Webinar #1: Structural Behavioral Interviewing	13
Webinar #2: Targeted Marketing	12
Webinar #3: Realistic Job Previews	18
Webinar #4: Competency-Based Training	11
Webinar #5: Public Service Announcements	4
Webinar #6: Frontline Supervisors	6
Webinar #7: Orientation & Onboarding	13
Webinar #8: Professionalizing DSP and Career Paths	12
Webinar #9: Peer Mentoring	6
Webinar #10: Online Toolkit	9
Webinar #11: Employee Development Part 1 - Employee Development Plans	6
Webinar #12: Employee Development Part 2 - Job Analysis	6
Webinar #13: Employee Development Part 3 - Employee Assessments	7
September/October 2020 Community of Practice	9
February 2021 Community of Practice	14
April 2021 Community of Practice	19
August 2021 Community of Practice	11
Office Hours 2021	1
Learning Lab #1: How Much Does a New Hire Cost? (April 2021)	0
Learning Lab #2: The Peer Empowerment Program (April 2021)	0
Learning Lab #3: Learning About Retention Through DSP Feedback (May 2021)	8
Learning Lab #4: The Ease of Applying on Your Organization’s Website (May 2021)	2
Learning Lab #5: Frontline Supervisor Assessments (June 2021)	3
Learning Lab #6: Targeting the Right DSPs (July 2021)	7
Learning Lab #7: Developing a Score Guide for the Structured Behavioral Interview (July 2021)	6
Learning Lab #8: Career Ladders (August 2021)	4

Providers who completed year two survey (2019 data) and had not yet participated in a kickoff became cohort two and were invited to participate in a seven-session, virtual regional kickoff series. The cohort two kick off was held over Zoom in late Fall 2020; it was moved to a virtual platform and delayed due to the pandemic. To accommodate the virtual platform, the original two-day kickoff was redesigned into a series of 7 training sessions held in each region. The goal was to be responsive to the challenges providers expressed with balancing priorities of responding to and managing the daily challenges of the pandemic with addressing workforce recruitment and retention needs in their organizations. Provider organizations who were part of cohort two and participated in the virtual kick-off did not engage in other training and consultation activities until early 2021. Table 25 shows cohort 2 organizations participation in each activity during 2020-2021. Note that multiple employees may have attended from some participating organizations.

Cohort 2 organizations participating in training and workforce consultation activities during 2021 will have an opportunity to see how their efforts to implement workforce strategies influence turnover and retention during 2021 after they have completed the annual workforce survey next year. Fewer organizations took part in cohort 2 training and workforce consultation activities despite efforts to offer technical assistance in several different formats. Cohort 2 workforce consultation activities occurred during the first wave of responding to the COVID19 pandemic. Cohort 2 organizations that did engage in training and technical assistance showed a preference for participating in group activities, such as learning lab webinars and office hours, over individualized consultation. Organizations also shared challenges in prioritizing participating in training and consultation with workforce consultations over the demands on their time related to ongoing challenges resulting from the pandemic. Many providers reported significant issues in finding enough workers and that they (the organization leaders, managers and administrators) were providing direct support to cover the gaps. All of these factors have influenced participation in training and consultation activities in 2021.

Cohort Two Organization Participation

Activity	Organizations in Attendance
Cohort 2 Kickoff Workshop Year 2 (virtual) October-December 2020	27
Individualized Consultation in 2021	3
Office Hours 2021	2
Learning Lab #1: How Much Does a New Hire Cost? (April 2021)	3
Learning Lab #2: The Peer Empowerment Program (April 2021)	2
Learning Lab #3: Learning About Retention Through DSP Feedback (May 2021)	2
Learning Lab #4: The Ease of Applying on Your Organization’s Website (May 2021)	1
Learning Lab #5: Frontline Supervisor Assessments (June 2021)	0
Learning Lab #6: Targeting the Right DSPs (July 2021)	1
Learning Lab #7: Developing a Score Guide for the Structured Behavioral Interview (July 2021)	1
Learning Lab #8: Career Ladders (August 2021)	1
February 2021 Community of Practice	6
April 2021 Community of Practice	4
August 2021 Community of Practice	3

In summary, fewer organizations took part in cohort 2 training and workforce consultation activities than cohort 1, despite efforts to offer technical assistance in several different formats. Cohort 2 organizations showed a preference for participating in group activities over individualized consultation.  Organizations from both cohorts shared challenges prioritizing participating in training and consultation activities over the demands on their time to focus on responding to the ongoing challenges of the pandemic that continued into 2021. Many providers reported significant issues in finding enough workers and that they (the organization leaders, managers, and administrators) were providing direct support to cover the gaps. All of these factors have influenced participation in training and consultation activities in 2021.

Discussion

Workforce Instability

A stable, competent DSP workforce is critical for the delivery of home and community-based services for people with disabilities to access, live, and work in the community. Unfortunately, nationwide there is a long term, widespread incidence of high turnover and vacancy rates among the direct support workforce (IDD; Scales, 2020). Organizations in Tennessee are also facing difficulties in recruiting, hiring, and retaining sufficient DSPs to meet this demand. There was a 63% DSP turnover rate in 2020 (Figure 10), and a 19% vacancy rate (Figure 11). This means that over half of the DSP workforce left their positions that year, and about one out of every five DSP positions were vacant. This results in unstable and limited services for people with disabilities, and great difficulties for organizations that employ DSPs to create a stable culture that supports DSPs. The COVID-19 pandemic also impacted the delivery of services to people and staffing (Hewitt et al., 2021). This was reinforced by organizations participating in training and consultation who shared stories of the unprecedented challenges they were facing finding and keeping DSPs. Eighty-seven percent of organizations said they were more short staffed after the pandemic than before the pandemic. As a result of health and safety precautions, many organizations shifted DSP work schedules and locations, and some staff were furloughed or positions eliminated (see Table 23).

Staff turnover is very costly for organizations. A typical rule of thumb for estimating costs related to turnover is that costs related to exiting an employee and replacing that position are about 25% of the annual salary of the position (Anderson-Hoyt et al., 2010). Research has shown that direct and indirect costs related to turnover per DSP that provides HCBS are $3,278; although, these data were collected in the early 2000s and have not been adjusted for inflation (Larson et al., 2016). Organizations in this study reported a total of 7,333 DSPs employed in 2020. Using the 25% of the DSP annual salary rule of thumb for cost of turnover and the average overall DSP wage of $11.09 per hour (Figure 8), costs of each DSP who leaves the position may be $5,766.80. At the rate of $5,766.80 per DSP, a 63% DSP annual turnover rate in the state of Tennessee results in an estimated $26,641,405 in costs related to DSP turnover.  Eliminating even half of these costs could result in an annual $1,816 bonus per DSP for the 7,333 DSPs reported.

Many DSPs leave their positions soon after hire

In Tennessee, of the 63% of DSPs who left their positions in 2020, 47% left in the first six months of employment.  Another 22% of those who left their positions left within six to twelve months of employment (Figure 10). This is an extremely high rate of DSPs leaving their position soon after starting, particularly for providing the personalized, skilled supports required of many DSPs. For comparison, 33% of DSPs who left their jobs in 2019 left in the first six months, and 18% left in 6 to 12 months tenure in organizations that employ DSPs in 26 states and the District of Columbia (National Core Indicators, 2020). In spite of the decrease in DSPs leaving in 0 to 6 months or 6 to 12 months of hire, the rates are still considered to be high which can signal the need to provide additional training and supports to new staff on the job, as well as job feedback, in order to develop adequate skills on the job. It can also signal that job candidates are not entering these positions with clear expectations about what the job entails. Many people are unaware of what is required in providing direct support. Without clear job descriptions or a realistic job preview, some candidates may be hired who are unaware of what will be required of them on the job. Such candidates may discover that this work is not for them soon after starting. Others may leave if they can find work in another industry. In Tennessee, organizations received resources in the DSP workforce toolkit, training, and consultation to assist them in reviewing their current practices that are known to influence turnover in the first six months of hire. Some of the topics covered through webinars and web-based DSP workforce toolkit include hiring practices including using referral bonuses in recruitment, ease of applying through organization website, sample job descriptions that align with core competencies, structural behavioral interview guides, realistic job preview and how to incorporate into the selection process, effective orientation, onboarding and peer mentoring, and the importance of effective frontline supervision in the first six months, along with other training topics and resources. Organizations with the goal of reducing their 0 to 6 month turnover through continued efforts to implement what they learned should have an effect over time.

Pervasive Vacancy Rates Influencing Recruitment and Retention

Vacancy rates are a key indicator in measuring workforce stability (National Core Indicators, 2020). Already historically high 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 sufficient DSP and FLS staffing cannot be secured and given the essential support services provided by these workers, existing workers are often asked to work long hours which is more likely to lead to burnout over time (Gray-Stanley, 2011; Vassos & Nankervis, 2012). The demand by people eligible for long term services and supports cannot be met without an adequate supply of DSPs and FLSs (Campbell et al., 2021). In Tennessee, vacancy rates increased from 2019 to 2020 for both DSPs and FLSs. The overall vacancy rate for DPSs in was 19% (see Figure 11) in 2020 and 13% in 2019. While there are variables such as the sample size that may have influenced the increase from one year to the next, the 2020 vacancy rate signals a pervasive problem with recruiting and retaining sufficient number DSPs to meet the growing demand for long term services and supports. It also likely shows the devastating effect that the COVID19 pandemic has had on HCBS provider organizations with regard to their workforce. Equally important is the vacancy rate for FLSs in Tennessee. The overall vacancy rate for FLSs in 2020 was 16% (see Figure 14) and 13% in 2019. 

Impact of COVID-19 on Organizations and the DSP Workforce

In a national survey of DSPs who provide supports, the COVID-19 pandemic impacted the DSP workforce and the people who receive supports from DSPs (Hewitt et al., 2021). Similar to these results, DSPs in Tennessee experienced positions which shifted schedules or changed work hours, locations or settings shifted, and some staff were furloughed or positions eliminated (Table 23). With notable cause for concern, eighty-seven percent of organizations reported that they were even more short-staffed than before the pandemic. The staffing crisis that existed before the pandemic deepened as organizations responded to the many challenges brought on by this unprecedented pandemic.

In terms of incidence of COVID-19 infections among DSPs and people supported, the average rate of infection in organizations were 13% and 12%, respectively. There was also incidence of death from COVID-19 among DSPs (<1% on average in organizations) and people who received supports (1% on average in organizations). Ongoing support and resources are needed for this workforce who are  responding to additional health and safety measures, dealing with grief of losing coworkers and people supported, and managing the impact of COVID-19 in their daily work. When asked about the training provided to new DSPs, organizations varied in what they provided to new staff. Twenty-six percent of organizations said new staff received typical orientation and preservice training, 64% said they received the typical orientation and preservice training as well as safety training related to the pandemic, and 4% said that typical orientation and preservice training were not provided. Some organizations may have struggled in their response to provide such training while also trying to staff unfilled positions and adhere to social distancing guidelines. Support in providing a unified health and safety response may be needed. Moving forward it will be important that the MCOs and TennCare understand the implications of the pandemic on all business and industry and the added challenges and costs this places on HCBS employers in terms of their ability to recruit and retain DSPs and FLSs when the wages are even farther below prevailing wages in most communities and the work DSPs do has grown even higher in terms of risks and responsibilities.

Low Wages and Limited Benefits

Organizations reported starting and average wages paid to DSPs. Average starting hourly DSP wages were $10.36 per hour.  The state average DSP wages were $11.09 per hour. These wages are low compared to the DSP national average (NCI, 2019). The average DSP who works 2,000 hours per year would gross only $22,180. The poverty line for a family of three in 2019 was $21,330 (US Health and Human Services, 2019). The average DSP supporting a household is set squarely in the working poor with these wages paid and is eligible for public assistance in programs that utilize the federal poverty line as a threshold. Multiple studies have demonstrated the relation between wages and DSP turnover rates (Houseworth et al., 2020; Anderson-Hoyt et al., 2010). Organizations that pay higher wages have lower turnover rates. Some organizations have attempted to provide incentives and bonuses to DSPs when they meet benchmarks. If funds allowed, this strategy could be modified with a larger wage increase or the wage increase could  occur earlier on in the DSP's tenure. This is an area where the QuILTSS Institute training model, when fully implemented, may influence the trajectory of this continued low wage trend.

Organizations reported whether or not they provided salary augmentations to DSPs who worked during the COVID-19 pandemic, due to the increased risk of exposure to the virus. Sixty percent of organizations paid salary augmentations related to the pandemic to their DSPs. These were most frequently paid through lump sum bonuses (Figure 15), as organizations were unsure that they could sustain wage increases over time. As wages increase among other industries, wages paid to DSPs need to be increased to keep DSPs in these jobs, while taking into consideration the added risks of providing human services in the midst of a pandemic.

Access to benefits is another important factor in keeping DSPs in their jobs.  Access to both paid time off and health insurance are additional measures that can increase DSP tenure, particularly in the face of a job market growing increasingly competitive. Only 66% of organizations offered paid time off to full- time DSPs, 31% offered paid sick leave, and 27% offered paid vacation to full-time DSPs (Table 6). Direct support is difficult and is a profession that has one of the highest rates of injury in the nation (Bureau of Labor Statistics, 2020). This, in addition to stresses of living in poverty, can make it difficult for DSPs to persist in this work without access to paid leave. Examining and improving paid leave policies are another strategy to supporting this workforce. Providing paid leave for employees who have been exposed to COVID-19 and to access COVID-19 vaccinations are also important strategies for controlling the spread of the virus.

Eighty-three percent of organizations reported offering health insurance to full-time DSPs, and 17% to part-time DSPs. However, for organizations that offered health insurance, an average of only 35% of DSPs used the benefit. The low proportion of DSPs who access health insurance through their employer signals another area to explore with organizations to better understand the influence of benefits on recruitment and retention. Organizations reported that the average cost of health insurance for an individual DSP was $155 per month, with average costs more than tripling for two-person coverage and increasing more than five times for family coverage (Table 7). The cost of health insurance may simply be too high for DSPs to afford the benefit alongside of other costs of living. If this is the case, more affordable options need to be explored. In a study of over 1,400 provider agencies who completed the National Core Indicators Staff Stability Survey, provision of paid time off and health insurance to DSPs was a predictor of lower turnover rates (Houseworth et al., 2020). As such, exploring ways to provide these benefits may provide cost savings to organizations by way of lower DSP turnover rates.

Access to support from frontline supervisors

Another common reason DSPs report leaving their positions is due to lack of support or the poor quality of support from their frontline supervisors (Hewitt et al., 2019). Frontline supervisors are a critical source of DSP support and training on the job. Competent frontline supervisors can improve the retention of DSPs. Without sufficient support, particularly for those who work in more individualized settings, DSPs may feel less equipped and more prone to finding other employment. Turnover and vacancy rates among frontline supervisors also contribute to instability of the DSP workforce. Twenty-one percent of frontline supervisors left their positions in 2020, with 23% of those frontline supervisors leaving with 0-6 months of hire (Figure 13). There was a 13% vacancy rate in frontline supervisor positions statewide (Figure 14). Further analysis on the reasons that frontline supervisors leave their position is warranted. The QuILTSS Institute training model includes a certificate that is aimed at Frontline Supervisors. Additionally, using National Frontline Supervisor Core Competencies in supporting and training FLSs, such as through the College of Frontline Supervision and Management, may be a promising strategy to help FLS increase their competencies (DirectCourse, 2021). Access to this training is being offered to providers as a part of the toolkit and consultation for provider organizations.

Workforce issues persist across regions and service types

Organizations reported their data across regions and service types, but regional data were difficult to interpret in some cases due to low sample size. In most cases, regional differences were slight, indicating that workforce issues persist across regions in the state. Some differences may be the result of geographic or market differences or a higher cost of living in certain regions. Furthermore, the COVID-19 pandemic may have affected certain regions of the state differently throughout 2020. Certain pieces of data were collected across 15 service types, but some organizations reported that it was difficult or impossible to delineate data across the service types. Participating organizations indicated that 62% of DSPs provide services across service types, and the majority of organizations pay DSPs the same wages when they work across service types (82% for the East and Middle regions and 73% for the West region).

Recommendations

Survey and Data Collection

In order to monitor trends in the direct support workforce related to turnover and vacancy rates, as well as wages, it is critical to continue to gather data. It will be important for TennCare and the MCOs to ensure adequate resources are available for survey development, implementation, and ongoing analyses. It is important to have sufficient staff to be able to conduct the follow-up with organizations to ensure surveys are received, questions are answered, surveys are completed, and encourage participation by stressing the importance of their voice. Ongoing relationships with the organizations are important, and should be fostered to ensure participation in future data collection efforts.

Ongoing support for provider organizations in Workforce Development

It is important to continue to support capacity building activities through MCO workforce development efforts to provide ongoing training and technical assistance in addressing workforce challenges for organizations across the state. Consistent with CMS's value-based programs, providing financial incentives for implementing evidence-based and best practices in workforce recruitment and retention, as well as financial incentives for specific workforce and quality of life outcomes, will increase participation. Organizations in Tennessee preferred participating in the training offered in different ways including webinars, learning labs, office hours at the organization, and at regional and state level trainings with their peers.

Full implementation of QuILTSS Institute Competency Based Training and Wage Incentives Model

Organizations participating in this Employment and Community First CHOICES Workforce QuILTSS Initiative have reported a readiness to participate in the QuILTSS Institute Competency Based Training and Wage Incentives model. In addition to exploring expansion of the current Direct Support Professional Apprenticeship for developing a workforce pipeline, ensuring full funding for supporting the implementation of the QuILTSS Institute Competency Based Training Model that includes wage incentives is an important next step in responding to workforce challenges in Tennessee. Ensuring effective evaluation to understand what is working and not working with regard to implementing this program as well as monitoring overall workforce trends of completers and non-completers will be essential to understanding effectiveness.

Evaluate the Effects of the COVID-19 Pandemic on the Workforce

It is clear that the COVID-19 pandemic caused significant challenges for providers that affected their workforce and ability to recruit and keep DSPs and FLSs. It is important to have a comprehensive understanding of their experiences throughout the COVID-19 pandemic. Nearly every business and industry (especially retail, manufacturing, and service industries) has been hit hard by the pandemic, and when combined with demographic shifts in the U.S., it is extremely hard for employers to find enough workers. Other industries have the ability to leverage capital by increasing prices to offset the costs of increased wages for new hires and existing employees. The HCBS provider industry cannot do this. Having a clear picture of the business context in which providers are trying to sustain a workforce is essential. Modifications to rates and incentives will need to be considered to maintain a strong provider network. 

Conclusion

This survey is part of a comprehensive project to learn about and support the direct support workforce in Tennessee. This third annual survey report includes important findings to inform data-driven solutions to support organizations to recruit, hire, and retain DSPs. These data, paired with the training and consultation on workforce solutions that is available to participating organizations, are intended to address the workforce crisis when implemented with fidelity over time. Organizations that participate are well-positioned to see a more stable and highly trained workforce over time. The 2020 data provide an additional reference point about the status of the DSP workforce issues among the 63 participating organizations.