Caring for Our Caring Workforce: A Stronger Direct Service Workforce

As our state ages, there’s increasing acknowledgement Colorado must do more to invest in the direct care workers who provide hands-on support for those with long-term care needs. While many of the underlying factors driving the field’s low retention and high turnover rates are easy to identify, there’s less consensus on what should be done to fix these problems. Below, we explore several promising practices.

Related: Our Caring Workforce: Who Are Colorado’s Long-Term Care, Direct Service Workers?

Increasing Wages & Benefits

Wages and benefits for direct care workers are low. While not the only way to strengthen this workforce, increasing compensation is perhaps one of the most important avenues to explore. To accomplish this, Colorado policymakers can consider:

Increasing Medicaid Reimbursement Rates

Most long-term care, including the support provided by the direct service workforce, is funded through Medicaid. Primarily set by state legislatures, reimbursement rates are created to compensate providers for their services. As throughout much of the country, Colorado’s reimbursement rates for long-term care, including direct service work, are low. Currently, Colorado’s reimbursement rate for personal care services is set at $18.44/hour, which is used to cover agency overhead, administrative costs, and both direct and indirect worker wages and benefits.

Colorado’s Department of Health Care Policy and Financing (HCPF), the agency which manages the state’s Medicaid program, also recognizes current rates are too low. Through its regular rate review process, where HCPF analyzes current provider costs and then recommends changes to how the state reimburses agencies, the Department determined fairer reimbursement for direct care would be $22.80/hour, over 20 percent higher than current rates. Though statewide budget constraints limit legislators’ ability to increase rates, doing so could provide considerable benefits to the direct care workforce.

Setting Wage Pass-Throughs & Wage Floors

Wage pass-throughs require agencies providing long-term care services spend a certain percentage or specific dollar amount of their Medicaid reimbursement on frontline worker wages or benefits. In contrast, wage floors set a minimum wage for direct service workers. Both actions have the same goal of increasing worker wages.

While currently used in both Washington D.C. and Connecticut, wage floors which specifically apply to direct care workers are infrequent. However, many states, including Colorado, have implemented limited wage-pass throughs, requiring a discrete amount of a one-time reimbursement rate hike be passed directly on to workers. Minnesota and Illinois however, have more expansive wage-pass throughs, and require a certain percentage of total Medicaid reimbursement for services be spent on direct care worker compensation.

Wage pass-throughs are not in and of themselves guaranteed to increase direct service worker retention, wages, or benefits. Wage pass-through evaluations show mixed results, and they note success is dependent upon factors including the size of the wage increase, which workers are included in the pass-through, and whether enforcement mechanisms exist. It’s especially important to note the impact of a wage pass-through is closely tied to total Medicaid reimbursement rates.

Providing Better Benefits

Though perhaps not as important as increasing wages, research suggests when direct service workers have access to more generous benefits, agency retention rates are higher. Much like wages, providers’ ability to offer better benefits is largely tied to Medicaid reimbursement rates.

Short of mandating providers offer benefits to direct service workers, states have taken action to incentivize agencies to do so voluntary. As an example, the Montana legislature passed a bill which provides higher Medicaid reimbursement rates to home care agencies that offer health insurance to their direct service workers. The program initially received $2.6 million in funding from the state legislature.

Greater Training & Advancement Opportunities

Research regularly shows inadequate training and a lack of career advancement opportunities contribute to the high turnover rate among direct care workers. More consistent, thorough training, as well as intentionally crafted career pathways can help address these problems. This may involve:

Increasing Training Standards

Across the country, training for direct care workers differs based upon state policies. Many states, including Colorado, lack a comprehensive, uniform training system which exists across providers. While some agencies provide comprehensive training, this isn’t guaranteed, and there are often gaps between what’s needed and what’s provided. Vague or inadequate training standards are especially problematic as the need for more specialized care increases.

States are taking a variety of actions to ensure workers have the training they need to succeed. With legislation, Iowa created a Direct Care Worker Task Force and Direct Care Worker Advisory Council, which in-turn developed the Prepare to Care Curriculum. This is a “comprehensive training package that prepares people to work in a variety of direct care settings.” Providers can voluntarily adopt this curriculum, which has been shown to increase provider efficiency and decrease worker turnover.

Though less holistic than work in Iowa, other states have also taken important steps to increase worker training standards and opportunities. For example, in response to their state’s changing needs, Arkansas and California expanded and tailored their personal care aide curriculum training requirements. Others, like Wisconsin, funnel funds to direct care worker training programs in an effort to grow access to quality programs.

Creating Career Pathways

A lack of meaningful career advancement opportunities is a major impediment to Colorado’s ability to attract and retain a quality direct care workforce. This gap is preventing workers from expanding their skills, growing their paychecks, and taking on increased responsibility. To address this problem, states are utilizing existing infrastructure to develop new opportunities. For example, Washington state leverages their workforce development councils to create new career ladders. Massachusetts developed a separate Extended Care Career Ladder Initiative, and invested $5 million to encourage “nursing homes and home care agencies to collaborate with community based organizations, career centers, local workforce investment boards and community colleges to improve knowledge and skills for staff and to provide career ladder opportunities.”

As part of these efforts, some states are also developing new direct service positions which require more training, entail greater responsibility, and have higher rates of pay. New York City, for example, piloted a home care, field support position. Individuals in these positions provided peer-to-peer support and mentorship for new direct care workers. When evaluated, organizations which hired for these positions had a 10 percent lower turnover rate. However, without additional funding, the pilot ended. More successful and sustained efforts like those in Indiana allow certified nursing assistants who receive additional training to administer routine medications. Higher wages come with these increased responsibilities.

Increasing Worker Protections

Direct service work is often challenging, but overlooked. To ensure workers have the support they need to thrive, cities and states have adopted different supports for these workers:

To further support direct care workers, New York City created a new Paid Care Division within the Office of Labor Policy and Standards. Created in 2016, the division develops policies regarding the paid care workforce and educates paid care workers about their rights and available resources. The Division also enforces worker rights and offers a centralized location for employees to lodge workplace complaints. As Mayor de Blasio noted, the department works to “actively address — through referrals to direct service providers, policy advocacy, and research — the poor working conditions and the high rate of workplace law violations faced by paid care workers.”

Several states, including Illinois, Hawaii, California, New York, and Nevada have also created Domestic Workers’ Bills of Rights. Often inclusive of workers beyond solely direct care—including housekeepers and nannies—these efforts offer different supports to workers—including protections from harassment, defined overtime regulations, and civil rights enforcement mechanisms.

To meet the state’s growing long-term care needs, Colorado must develop a strong direct service workforce. To do this, several large hurdles need to be addressed, including low wages, poor training, and limited career ladders. Developing solutions to these various needs will be complicated, however, Colorado can learn from research and efforts in other states, individualize solutions, and create tailored responses to support our caring workforce.