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Low wages, long hours, high turnover, and lack of opportunities for advancement. These are just some of the factors contributing to the direct support professional (DSP) workforce crisis – there are just not enough DSPs to meet the demand for their services.
DSPs provide care for older adults and people with disabilities who live in the community and help their clients lead the lives they want to live.
Approximately 4.5 million DSPs serve more than 7 million people who receive HCBS. The number of people who need DSPs is expected to grow as the population ages. According to PHI, job demand for DSP services is expected to increase by 35% in the next decade (compared to a growth of 8% for all occupations), creating more than 9.3 million job openings.
The already dire DSP shortage was further exacerbated by the COVID-19 pandemic when DSPs left the workforce in droves to take care of their own families. The shortage has meant that some provider agencies can’t meet the needs of their communities, turning people away, closing programs and putting people on long waitlists for services.
Solving the DSP shortage will require addressing numerous issues, including increasing wages to attract and keep new workers.
A recently-passed piece of legislation called the Access Rule, requires that at least 80% of all Medicaid payments for HCBS to be spent on compensation for DSPs.
According to the U.S Bureau of Labor Statistics, in 2023, CNAs made a median hourly wage of $18.33 and annual salary of $36,220 while DSPs made a median hourly wage of $16.12 and an annual wage of $33,530. According to PHI, in 2021, nearly two in five direct care workers lived at or below 200% of the federal poverty level.
The case for higher wages for DSPs has been stymied in part by the misconception that DSPs provide relatively unskilled labor in contrast to other personal service workers, such as certified nursing assistants (CNAs).
One way to improve wages for DSPs would be to offer programs that result in a certification similar to programs that offer certification for nursing assistants.
“This mindset that exists that direct support professionals provide unskilled labor, and that it's an entry level job that anyone can do, but it couldn't be further from the truth,” says Dan Hermreck, Director of Certification and Accreditation at NADSP. “The comparison to certified nursing assistants has often been made but with the caveat that CNAs have more skills or are more professional, and I think that comes from the fact that they have a certification they can point to, and this is partly what motivated us to offer a national certification for DSPs based on the specific set of skills that CMS requires of DSPs.”
NADSP’s E-Badge Academy offers certification in alignment with 12 core competencies required for DSPs by CMS, including communication skills, crisis prevention and intervention, cultural competency, health and wellness and more. NADSP requires 50 hours of NADSP-accredited education for their first level of certification and an additional 50 hours for their second level of certification. There is also a third level which doesn’t require additional hours of education.
In addition to educational hours, DSPs describe and reflect on their own experiences as part of the E-Badge Academy. For example, to earn a badge for crisis intervention, a DSP would describe a situation in which they used this particular professional skill, and then explain how that example of their work aligned with the values of the NADSP Code of Ethics. There are other badges available that represent other professional skills and those badges stack together to meet certification requirements for three levels.
Human services organizations in 29 states across the country offer the E-Badge program to their DSPs and so far, NASDP has awarded 5,250 certifications through its program.
“It's not our desire for it to be something that's mandatory before you can do work in this field, it's more of a way for people who want to stay in the field and make it a profession to distinguish themselves from folks that are just looking for a job,” says Hermreck. “And we do see improvements in retention among agencies that use our DSP certification program.”
Kelly Baker is the Career Ladders Program Coordinator at Penn-Mar, a human services agency that crosses the border between Pennsylvania and Maryland. The agency serves about 400 people, mostly with intellectual or developmental disabilities. It employs more than 500 people, including DSPs. Baker says that DSPs at Penn-Mar are offered the opportunity to participate in the NADSP E-Badge Academy after working there for three months, but it isn’t a requirement. ‘We leave it open-ended so that when it makes sense for that DSP in their life, they have the flexibility in that time to dedicate to the program,” she explains.
Baker says DSPs who go through the E-Badge program get a chance to really think about what it means to serve people and come away with a stronger sense of their roles. “People reflect on things like delivering person-centered care, and then implement it in their work. So they're not only doing that job and doing a good job, they're also gaining confidence and self-esteem."
The program has also helped improve retention, Baker explains, “It really helps them to stay because they feel they are bringing value and expertise to their jobs.”
Maria Swift has been a DSP for five years, all of them at Penn-Mar. A few months into her job, her manager approached her and suggested she enroll in the E-Badge program. “I really wanted to go a little bit further in the field, and make sure I understand the people I'm supporting,” she said. Over the course of about four and a half years, Maria completed all three levels of the E-Badge program. For completion of the first level, she received a bonus payment and an increase of 50 cents per hour. For levels two and three, she received another lump sum bonus. The program was free to her. “I liked it because it also requires 100 hours of education through either NADSP or other organizations and sources, and it really gave me more confidence in my skills at work,” Maria says.
Pay increases tied to DSP certification, whether through NADSP or other organizations, are mostly up to the employer, especially since DSPs who serve people who receive HCBS are paid through CMS. CMS, together with states, sets structured pay rates for DSPs and currently, these rates don’t differentiate between DSPs who have earned a certification and those who have not. But that seems to be poised to change soon.
Some state budgets have included measures to address the direct worker shortfall.
In May, Illinois passed a new state budget that will increase wages for DSPs by $1 an hour.
President and CEO of the Illinois Association of Rehabilitation Facilities says, “This budget will keep us on the path for parity with the state’s minimum wage that will increase to $15 next January, and that will allow us to compete against the wage packages offered by restaurants, retailers and others in the marketplace.”
In Minnesota, legislators and policy makers are working together with CMS to link DSP certification to increased pay. In March of 2018, the Minnesota Olmstead sub-cabinet approved a far-reaching report, entitled “Recommendations to Expand, Diversify and Improve Minnesota’s Direct Care and Support Workforce Olmstead Subcabinet, Cross-Agency Direct Care and Support Workforce Shortage Working Group” that presented recommendations to address the direct care shortage.
The report led to the development of Minnesota Statute 256b.851 Community First Services and Supports, Payment Rates, on the establishment of a rate structure for DSPs and also sustainable DSP reimbursement rates.
Jesse Bethke Gomez is Executive Director of the Metropolitan Center for Independent Living (MCIL) in Minnesota and was one of the authors of the report. With support from a Bush Foundation Community Innovation grant, MCIL has been working with legislators, educators, government officials, DSPs and other stakeholders to develop a DSP certification curriculum that can be offered through universities, community colleges and other institutions of higher education that would be tied to increases in pay through CMS.
“Should Minnesota adopt the Certified DSP curriculum leading to this new credential role of a Certified PCA and tie it through legislation to the median wage of a Certified Nursing Assistant (CNA) through the already existing 256b.851 Minnesota Statute, this could mean an increase in pay for DSPs of $4 an hour,” says Gomez.
According to the Bureau of Labor Statistics, in May 2023, in Minnesota, the median wage for CNAs was $20.65. For this same time, the median wage for DSPs was $16.64, making for a wage differential of $4 an hour.
The curriculum, like that offered by NADSP, is based on the 12 core competencies for DSPs developed by CMS.
In addition to the curriculum, MCIL is working within a DSP pay rate framework passed in the 2021 Minnesota legislative session that would identify competitive workforce factors and their related component values that would result in DSPs having an hourly wage equal to that of CNAs.
“What we will bring forth is a formalized educational opportunity leading to the credential of a certified PCA/DSP that is linked to a formalized pay structure that offers compensation commensurate with those of other healthcare certificate holders, such as CNAs,” says Gomez.
Gomez views the DSP workforce crisis, and especially the push for higher wages, through a truly intersectional lens.
“The American Dream has always been something you achieve through education. By bringing forward this curriculum and others like it for PCAs and DSPs along with bringing the legislative framework to accommodate pay increases for people who get the credential certification, we create a transformative effect,” he explains. “It ensures that people stay in their homes, we reduce the likelihood of people dying because they have the DSP home support they need for daily living and we transform our economy during this time in which our population is aging rapidly. This way we increase our ability to care for one another through education.”
Gomez also notes that an educational program leading to certification and a higher wage provides a path to success for immigrants as well as minorities and women, who make up the largest portion of the DSP workforce.
“It’s all about advancing the ability of people to care for one another,” Gomez says.