Employment and Community First CHOICES Workforce QuILTSS Initiative Survey 2019: Year Two Report


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.  These results signal significant and widespread challenges that organizations in Tennessee are facing in recruiting, hiring, and retaining sufficient DSPs to meet this demand.  There was a 47% DSP turnover rate in 2019 (Figure 10 - see DSP Retention page), and a 13% vacancy rate (Figure 11 - see DSP Retention page).  This means that nearly half of the DSP workforce left their positions that year and about one out of every seven DSP positions is 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.  Furthermore, organizations are taxed with extremely high costs related to turnover.  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.  Research has shown that costs related to turnover per DSP that provides HCBS are $3,278 (Larson et al., 2016).  Organizations in this study reported a total of 12,975 DSPs employed in 2019. At the rate of $3,278 per DSP, 47% DSP annual turnover rate results in an estimated $19,990,064 in costs related to DSP turnover.  Eliminating even half of these costs could result in an annual $750 bonus per DSP.

Many DSPs Leave Their Positions Soon After Hire

Of the 47% of DSPs who left their positions in 2019, 53% left in the first six months of employment.  Another 33% of those who left their positions, left within six to twelve months of employment.  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, according to the NCI Staff Stability Survey, of organizations that employ DSPs in 26 states and the District of Columbia, 35% of DSPs who left their jobs in 2018 left in the first six months and 20% left in 6-12 months tenure (NCI, 2019).  This 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.

Low Wages and Limited Benefits

Organizations reported starting and average wages paid to DSPs.  Average starting hourly DSP wages were $9.88 per hour.  The state average DSP wages were $10.56 per hour.  These wages are very low.  The average DSP who works 2,000 hours per year would gross only $21,120.  The poverty line for a family of three in 2019 is $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 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 happening earlier on in the DSP's tenure.

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 57% of organizations offered paid time off to full-time DSPs, and 26% and 30% of organizations offered paid sick leave and paid vacation, respectively (Table 6 - see DSP Benefits page).  Direct support is difficult and one of the highest rates of injury professions in the nation (Bureau of Labor Statistics, 2016).  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.

Eighty-one percent of organizations reported offering health insurance to full-time DSPs and 21% to part-time DSPs.  However, for organizations that offered health insurance, an average of only 34% of DSPs utilized the benefit.  The low proportion of DSPs who access health insurance through their employer signals another area where organizations could better support DSPs or verify if DSPs are obtaining health insurance from other sources.  Organizations reported that the average cost of health insurance for an individual DSP was $133 per month, with average costs more than tripling for two-person coverage and increasing more than five times for family coverage (Table 7 - see DSP Benefits page).  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.

Access to Support From Frontline Supervisors

Another common reason DSPs report leaving their positions is due to lack of support or poor quality support from their frontline supervisors.  FLS are a critical source of DSP support and training on the job.  Competent FLS can improve retention of DSPs.  Without sufficient support, particularly DSPs that work in more individualized settings, may feel less equipped and more prone to finding other employment in the absence of such support.  Turnover and vacancy rates among FLS can also result in instability of the DSP workforce.  One quarter of FLS left their positions in 2019, with nearly one-third of those FLS leaving with 0-6 months of hire (Figure 13 - see Frontline Supervisors page).  There was a 13% vacancy rate in FLS positions statewide (Figure 14 - see Frontline Supervisors page).  Further analysis on the reasons that FLS leave their position is warranted.

Workforce Issues Persist Across Regions and Service Types

Organizations reported their data across regions and service types. Regional data are 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 costs of living being higher in certain regions.  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 47% of DSPs provide services across service types, and the majority of organizations (85%) pay DSPs the same wages when they work across service types.


This survey was designed to gather important and relevant information about the direct support workforce in Tennessee, but it does have some limitations.  Some of these can be modified in future surveys to better collect information from organizations. 

Seventy-five organizations completed the 2019 survey, including 20 organizations in the East, 33 in the Middle, and 22 in the West.  There were questions that were not answered by all organizations.  This made the sample size for each region even smaller.  Therefore, analyses comparing regions need to be interpreted with caution for questions where samples are small. In some cases, sample sizes were simply too small to examine the data by region.

Lastly, caution is needed when comparing the state and regional survey results from 2018 (year 1) and 2019 (year 2).  The 2019 survey had a significantly larger sample with 40% more organizations completing the survey.  Therefore, the data from 2018 and 2019 actually reflect two different groups. This may lead to inaccurate assumptions when making direct comparisons between the two groups.


This survey is part of a comprehensive project to learn about and to support the direct support workforce in Tennessee.  This second annual survey report included important findings to provide data-driven solutions to support organizations to recruit, hire, and retain DSPs. These data, paired with training and consultation on workforce solutions available to participating organizations, are intended to address the workforce crisis when implemented with fidelity over time.  Organizations that participate are well-positioned to see a more stable and highly trained workforce over time.  These data provide an additional baseline data point about the status of the DSP workforce issues among the 75 participating organizations.

An important part of this effort is for provider organizations to continue working to identify key areas for improvement, gather further data and information about the nature of the challenges faced, and address workforce challenges in a targeted manner.  Collecting data for decision-making is a key piece in evaluating these efforts.