Recruitment and Retention of Direct Care Workers During the COVID-19 Pandemic: Challenges and Opportunities

Abstract

The COVID-19 pandemic exacerbated the challenges of home- and community-based service (HCBS) providers in recruiting and retaining direct care workers (DCWs). One of the largest and fastest-growing occupations in the U.S., DCWs are essential to the growing population of persons in need of long-term services who wish to remain in their homes. We surveyed all Connecticut Medicaid HCBS providers about their pandemic-era recruitment and retention challenges, strategies employed to overcome them, recommendations for regulatory and policy changes, and use of American Rescue Plan Act (ARPA) funding. Respondents (n = 447) noted the continuing key roles played by compensation and working conditions, emphasized unintended consequences of government unemployment policies, provided creative suggestions for professionalization of DCW work, and suggested best practices for consideration, including the success of word-of-mouth and employee referral bonuses in recruiting and the importance of organizational culture in retention.

What this paper adds

• • A statewide survey of all Medicaid HCBS providers in one state adds substantial insight into the causes of pandemic-era and continuing recruiting and retention challenges of direct care workers.

• • Providers described creative strategies employed by their organizations to meet these challenges and shared the extent to which they were effective or ineffective.

• • Survey results indicate that ARPA incentives for maintaining a stable provider network were at least partially met through innovative strategies under unprecedented circumstances that were not part of the standard playbook for DCW recruiting and retention.

Applications of study findings

• • Survey results point to a number of creative or best practices for consideration by other providers and other states facing similar challenges that may be replicated, expanded, or made scalable in recruiting and retaining DCWs.

• • Providers made numerous suggestions for policymakers and regulators to consider in supporting the creation of a robust home care workforce.

Introduction

Direct care workers (DCWs) who provide home- and community-based services (HCBS) to older adults and people with disabilities constitute one of the largest and fastest-growing occupations in the U.S. (Kelly & Deichert, 2023; PHI, 2023). Low wages, difficult working conditions, and DCW staff shortages have been documented at least since the 1980s (Yamada, 2002). Advocates have long urged policymakers to identify and implement strategies for the development and maintenance of the DCW workforce through enhanced wages and benefits, training and career ladders, and expansion of the labor pool (Stone, 2004). Only incremental progress has been made over the decades, however, as the growing preference of people to age in place and the prominence of Medicaid as a payer of HCBS has exacerbated DCW recruitment concerns (Scales & Lepore, 2020).

The COVID-19 pandemic underscored the need for DCWs. The demand for quality alternatives to institutional care grew due to mortality and morbidity threats, and requests for HCBS surpassed its availability (Miller & Beauregard, 2023). The pandemic increased the challenges experienced by DCWs such as exposure to the virus and lack of personal protective equipment (PPE), pandemic-specific training, paid time off, and compensation for hazardous working conditions. It also intensified longstanding challenges experienced by states and provider agencies in recruiting and retaining DCWs to serve populations needing Medicaid-funded HCBS (National Governors Association, 2022). In a competitive labor market, providers found it increasingly difficult to recruit and retain DCWs since many workers were attracted to employment in sectors with similar wages but more flexible schedules and other benefits (Khavjou et al., 2023). Yet the pandemic also provided an opportunity to address longstanding workforce issues with streamlined protocols, technology-based solutions, and other creative recruitment and retention strategies (Scales, 2021).

One federal pandemic response was the American Rescue Plan Act of 2021 (ARPA), designed to provide direct relief to Americans and contain the spread of COVID-19. ARPA provided states an increased federal share of Medicaid HCBS costs as long as ARPA funds were invested in activities that enhance, expand, or strengthen HCBS, including provider recruitment and retention initiatives (Sullivan, 2021). Connecticut’s ARPA implementation plan was designed to enhance providers’ ability to attract and retain a high-quality DCW workforce. The plan included rate increases and incentive-based payments for Medicaid HCBS providers, wage increases for DCWs, and a one-time stabilization payment for HCBS providers equal to 5% of their State Fiscal Year 2021 expenses.

To assist the state in conducting a policy evaluation of the implementation and effectiveness of this use of ARPA funds, the Connecticut Department of Social Services (CT DSS) contracted with the University of Connecticut, Center on Aging (UConn COA) in 2023 to survey all Medicaid HCBS providers in the state that employed DCWs. Survey results allowed the state to better understand recruitment and retention difficulties faced by Medicaid HCBS providers during the pandemic, and to learn and share strategies that were successful in rebuilding workforce structures. This paper responds to challenges from Scales (2021) and the Bipartisan Policy Center (2023) to document the impact of the pandemic and ARPA funding on DCW recruitment and retention. It explores how and whether providers’ use of ARPA funds fulfilled the state’s policy goals, and summarizes lessons learned that respond to longstanding and continuing recruiting and retention challenges. Although this research is specific to DCWs working in home and community settings, recruitment and retention challenges are similar to those for workers in institutional settings such as nursing homes, and strategies explored may apply across settings.

Methods

The Survey

The survey included seven qualitative and eleven quantitative questions based on existing literature about recruitment and retention challenges, strategies utilized to retain and recruit DCWs, and use of ARPA stabilization funds in those efforts (Survey available in Supplement 1). Feedback on a draft survey from CT DSS staff and provider organization representatives was incorporated into the final survey. It was not subsequently pilot-tested. Respondents answered based on their experiences from March 2020 through the date of the survey.

Recruitment and Data Collection

Initial survey invitations were sent in February 2023 to email addresses of 1,504 individuals from the 560 Medicaid HCBS provider organizations supplied by CT DSS. The list included all Medicaid HCBS providers in the state employing DCWs, representing 100% of the population of provider organizations. Providers varied greatly in size, number of employees, and diversity of services, and included home care, personal care, homemaker/companion, care management, and visiting nurse agencies, adult day programs, independent living agencies, area agencies on aging, and providers for individuals with behavioral health, brain injuries, autism, or intellectual/developmental disabilities. The emails specified the type of information requested, and persons with questions about who should complete it were instructed to contact UConn COA to help identify the best respondent. Individuals with appropriate institutional knowledge were largely agency heads or HR personnel.

Following initial emails sent February 12, 2023, reminder emails were automatically sent daily for five additional days or until the survey was completed. Providers were given until February 20, 2023 to respond with an extension until March 3, 2023. Of 1,504 initial email invitations, 362 completed surveys were returned. The list of individuals who did not respond to the initial invitation (n = 1,142) was reviewed and individuals with duplicate organizational tax IDs (n = 424) were deleted if a provider with the same tax ID had completed a survey following the initial invitation. The same survey was emailed in late March 2023 to the remaining 718 non-responders, plus an additional 5 provider organizations newly identified by CT DSS (n = 723). Reminder emails were sent daily for two additional days or until the survey was completed. Providers were given until April 21, 2023 to respond. Eighty-five surveys were received following the second invitation, resulting in 447 completed surveys from 382 provider organizations. Of the 565 provider organizations invited to participate in the survey, 67.6% (n = 382) completed at least one survey. Some larger providers with multiple offices completed more than one survey (46 providers completed 2 surveys, 6 completed 3 surveys, and 1 each completed 4 or 5 surveys).

Data Analysis

Survey data were collected and managed using Research Electronic Data Capture (REDCap) (Harris et al., 2019), a secure, HIPAA-compliant, web-based software platform that supports data capture for research studies. Quantitative data were exported from REDCap into the Statistical Package for the Social Sciences (SPSS) version 28 and analyzed. Since more than one respondent completed the survey from some provider organizations, the unit of analysis for quantitative results is the respondent. We conducted a sensitivity analysis of the quantitative data with one response per organization, with no notable difference in results. Specifically, one response was randomly selected from organizations submitting multiple surveys and an analysis was conducted on the unduplicated surveys (n = 382). Outcomes were compared between the group with and without duplicates. Descriptive statistics were run on all quantitative questions. Qualitative data were exported from REDCap into SPSS, formatted as single transcripts per survey question in Word and imported into ATLAS.ti version 23 to systematically identify and organize themes. Following an initial review of the data, deductive, or directed content analysis was used to develop a codebook as a guide for broad categories and subconstructs for more narrow categories (Crabtree & Miller, 2022; Mayring, 2000). Three researchers used a cyclical, iterative approach to data coding and refining themes within categories until saturation was evident or no new themes emerged (Busetto et al., 2020). Agreement between researchers established strong intercoder reliability (O’Brien et al., 2014). When disagreement in coding occurred, researchers discussed the text until they reached consensus. The Consolidated criteria for REporting Qualitative research (COREQ) was used as a guide (Tong et al., 2007) (Supplement 2).

Results

Provider Recruitment and Retention Challenges

Employee turnover rates provide a strong measure of the extent of retention challenges. Most respondents (58.4%) reported that their organizations regularly track turnover rates. Of those that do, 69.8% reported that turnover rates increased during the pandemic compared to the year prior to March 2020, and nearly half of those said turnover rates increased by more than 50%. To gain insight into the reasons for increased turnover, respondents were asked to select from a dropdown list the top reason given by DCWs who left their position during the pandemic. Two reasons accounted for more than half of responses: fear of catching COVID-19 (27.3%) and low pay (27.0%). These were followed by personal health concerns (11%) and childcare/other family issues (10.5%.) Fewer than 10% indicated that the top reason for turnover was better opportunities in another field, stressful working conditions, too many hours, or an employer vaccine requirement (Figure 1).

Figure 1.

Top reason direct care workers left their positions.

An open-ended question asking respondents to describe in detail, with examples, their DCW recruiting and retention challenges during the pandemic yielded numerous and often impassioned responses. Unsurprisingly, COVID-19 safety concerns, such as workers’ and clients’ fear of the virus, apprehension of going to clients’ homes, reluctance to receive required vaccinations, and time off for exposure and recovery, figured prominently in responses.

The acuity of the clients that we serve along with poor health and limited access to health care professionals lead many direct care staff to be fearful of direct engagement during the pandemic. Families for our in-home services program were also fearful of our staff coming into their homes and therefore canceled over 50% of services. This led to staffing shortages with limited hours increasing staff turnover.

Many were too afraid to work, gave their notice and never returned. About 40% left.

Staff pool was decreased due to hiring only vaccinated staff.

Other interrelated responses reflected the exacerbation of pre-COVID-19 recruiting and retention challenges. Numerous providers stated that an increase in poor worker quality hindered their recruitment and retention efforts, particularly lack of professionalism.

[T]he quality of applicants [has] decreased. We are seeing more applicants without driver’s licenses or extensive criminal backgrounds. When we are able to recruit quality caregivers they quickly leave for jobs that pay more or do not have transportation with no reimbursement… It is truly heartbreaking how we are daily turning away families in need of care because we don’t have quality staff.

The most serious problems we are facing is no willingness to work by newly hired employees. Work ethics change. Call outs are no longer exceptions, they became rule... After they do everything else (their appointments, personal issues, etc.) if there is time left for work, they might attend… People are applying for positions far exceeding their qualifications.

Low wages for direct care workers, often tied to Medicaid reimbursement rates, were also frequently noted.

The Medicaid service rates are too low and not attractive in general but during the pandemic was a catastrophe!!!!! Poor elderly people … haven't received the home care timely and waited their turn.

Medicaid just simply does not reimburse the agencies enough to pay employees even $18.00 per hour to retain good, dedicated caregivers when we are competing with Walmart, McDonald’s and Burger King.

One frequent response that was not offered as a selection in the dropdown menu is traceable to COVID-19-era federal and state unemployment policy decisions. About a quarter of respondents reported that existing and potential employees left the workforce entirely, deeming it in their own financial self-interest. Unemployment compensation at that time was preferable to and more remunerative than working at low-wage jobs, particularly when coupled with the opportunity to avoid COVID-19 exposure and remain home with children at a time of forced home schooling. Enhanced unemployment and other benefits made recruitment and retention of DCWs far more difficult for many providers.

Our biggest issue has been the State working against us. Connecticut made it possible for people to NOT have to work with all the unemployment that was handed out and all the extra income people received and the extra SNAP benefits. We have had numerous people tell us they make more money staying home.

A lot of people we reached out to said that they have the time and experience and can work, but … they are making more money staying home. A LOT of people said this.

It was very difficult to find staff during the pandemic as most staff voluntarily quit their job with Agency to get additional unemployment benefit funded by the DOL. Unemployment notice[s] tripled.

In addition to fighting the “competition” of unemployment benefits, providers noted increased competition for employees from organizations providing greater wages and benefits. Nurses were particularly difficult to find due to competition from hospital incentives and traveling nurse organizations. Other caregivers were quickly hired by private agencies offering higher hourly rates.

The pool agencies are taking all the available staff and then selling them back to us at outrageous prices...ESPECIALLY NURSES.

We have staff leaving for higher compensated positions like traveling agencies and with larger system hospitals.

For the home health aide role, potential candidates were offered higher hourly rates by non-healthcare employers such as grocery stores, fast food chains, Amazon warehouses, etc.

Since some challenges may have eased by the time of the survey in early 2023, respondents were asked to describe which issues were still creating challenges, and in what way. Low pay continued as the top challenge and was by far the most common response.

Low pay is still causing challenges. In a nutshell, the amount the state pays is not enough to offer competitive wages.

Caregivers consistently state that they are paid too little. Our private pay clients pay more for services than the state pays for services for the client. Therefore, the caregivers cannot be paid for state clients as much as they can be paid for private pay clients.

Competition from other employers and better opportunities in other fields continued to challenge providers’ recruiting and retention efforts. While closely related to the issue of low pay, competition and better opportunities may also involve more attractive working conditions.

Staff are leaving their [DCW] roles for the same or higher pay to work in a desk job and not have the physical or emotional stress of caring for people.

[DCWs] do not have the ability to have a flexible working schedule or environment as they are required on-site at a specific time to provide care to the individuals.

Better opportunities elsewhere - they will understandably go to ‘the highest bidder' if it's the same work. And people can go to any clothing store for a lot more.

Childcare and other family issues also continue as a pressing concern for many providers.

One of them is still “Child Care.” Some employees cannot work because they don't have someone to watch their kids while at work.

While fear of COVID-19, vaccination requirements, and other personal health concerns have decreased dramatically as a continuing barrier to DCW recruitment and retention, they have not disappeared entirely.

Employees are still frightened by the risk factor of catching COVID-19 and spreading the disease to their families at home.

Vaccine requirement still limits potential employees.

A small number of providers noted continuing challenges with stressful working conditions, transportation difficulties, and overall worker quality. The potential consequences to clients of recruiting challenges were summarized by one provider:

Due to our inability to recruit staff over the last 3 years we have a wait list that is months long for our services. We have had to cancel services last minute for some of the individuals in our program because we didn’t have backup staff available to fill in for staff vacations or sick calls.

Strategies to Recruit and Retain DCWs

Providers did not stand still in the face of these challenges. The survey asked which of six specific strategies they used to recruit and retain DCWs during the pandemic, and to indicate, if used, how much these strategies helped (a lot, a little, or did not help) (Figure 2.) The strategies used by a majority of providers that helped the most (either a little or a lot), were raising base pay (70.5%), giving bonuses (58.0%), and increasing flexible work hours (55.7%). A majority also provided additional training opportunities, but only 37.4% said it helped, while fewer than half improved benefits or enhanced career paths, and only a quarter said those strategies helped.

Figure 2.

Provider strategies to retain and recruit direct care workers.

In addition to those noted above, providers were asked to report any additional strategies they used to address DCW recruitment and retention, and to give examples. The most common response concerned enhanced recruiting strategies for new employees involving creative advertising and marketing efforts such as referral incentives, job boards and job fairs, social media, school career centers, and word-of-mouth.

We implemented an 'employee intensive referral program' which would give a money bonus payment to the referrer. The applicant referred to hire must pass the background check, drug test and a 60-day probation period before bonus is issued to the referring employee.

Our company utilized sponsoring adds on Indeed, posted jobs on multiple recruitment pages through our internal recruitment system including LinkedIn, college career center, company website, internal referral programs, Monster.com, job boards, job fairs, myCNAjobs.com, Neuvo, and local unemployment program.

Several providers also noted the advantages of automating parts of the recruiting and onboarding process.

We started using more online tools to help with the onboarding process, which eliminated some contact and had a faster processing time.

Improvements in organizational culture were noted by many providers as a successful and meaningful strategy for recruitment and retention. These included staff get-togethers, mentorship programs, employee wellness, caregiver recognition events, enhanced communication, and an emphasis on company values and ethical practices.

We improved our employee wellness offerings this year beyond fitness. We offered meditation sessions, a painting event, financial wellness education series, team challenges.

Stressed our values and good ethics in stressful times and maintained our motto of “just want to do the right thing.”

We have worked very hard on the culture of the agency, striving to create a positive, inclusive environment. Increased staff appreciation events, hand out gift cards when we 'catch' someone going above their job requirements.

Providers described additional monetary and non-monetary incentives valued by employees that enhanced recruiting and retention, such as gift cards, mileage reimbursement, gas stipends, remote work, and accelerated pay periods.

We also started a monthly discount/reimbursement to local attractions for employees (e.g., reimbursement for non-work-related items like gym/exercise class, lift tickets, concert/theatre tickets, etc.)

Weekly pay periods: Many of the employees retained like the weekly pay. I have gained employees because they live paycheck to paycheck and having a weekly pay as opposed to bi-weekly helps staff keep up with budgeting at home.

Most Effective Strategies

To assist the state in compiling a set of creative/best practices to share with others serving the state’s HCBS population, and to help maintain a sustainable provider network with quality staff, providers were asked to relate which of their pandemic-era recruitment and retention strategies were most effective. For some, no strategy proved effective, but most noted at least one successful strategy. Compensation-related incentives for both recruitment and retention were unsurprisingly mentioned most often, more than twice as often as any other response.

Increasing pay to be competitive was crucial in recruiting new hires.

The most effective retention strategy was to increase present employees’ rates of pay with a percentage increase to keep higher than starting employees’ rates.

We utilized sign-on and retention bonuses. Retention bonuses for staff that committed to working through the pandemic were probably the most effective in retaining staff.

A few providers noted that although increased compensation was a somewhat effective pandemic strategy, it may not be sustainable.

Adjusting hourly rates was the best result, however, homecare margins are extremely low and without a pay increase from payors, it will be difficult to sustain operations with this dramatically increasing expense.

Many providers noted that the enhanced advertising and marketing strategies adopted during the pandemic were their most effective innovation. Many cited employee referral programs as most effective; others noted word-of-mouth, social media, and career fairs.

Our most effective staff recruitment strategy during the pandemic was “word of mouth.” Existing employees talking to friends and/or family members about an opening, and quick screening and decision to get hired.

Job Fairs -- conducted on site interviews and hired qualified candidates immediately.

A small number of providers recruited non-traditional candidates with some success.

[Organization] tries to recruit from retired individuals who seek less hours, or possibly college students who can’t work many hours due to their schools’ schedules.

Improvements in working conditions and company culture were also frequently mentioned as effective recruitment and retention strategies. Working conditions included flexible schedules and assignments, remote work, and accommodations to increase work–life balance. Organizational culture improvements involved employee appreciation, enhanced communication, mentoring, and promoting values and ethical practices.

The most effective recruitment/retention strategies during the pandemic for us was letting the staff know how much we appreciated them going to work and providing care for our clients.

Our values-driven approach and genuine, family-friendly, supportive atmosphere (established way before the pandemic) also helped. We try to truly listen and be responsive to concerns, ideas, and challenges.

Mentor Program - new hires get matched with a tenured [DCW] to help them learn and embrace our mission, and our culture. Mentor supports the new hire throughout their first 45–60 days. 50% improved retention after 90 days over those w/o mentors.

Providers also noted training and career advancement as a best practice in retaining employees.

We changed our structure to add senior and lead positions within our program teams. This was done to give direct staff a career path towards a management role. This allowed staff with more experience or higher education to be promoted and take on additional duties while still carrying a lesser caseload.

Use and Effectiveness of ARPA Funds

Providers received ARPA agency stabilization funds in 2021/2022 and were asked to what extent these funds were used for recruitment and retention of DCWs, examples of these, and their effectiveness. They were also asked what additional initiatives, if any, were funded by the stabilization payment. Compensation-related incentives including benefits, bonuses, and paid time off, were cited most often.

The funds were used to increase clinician pay across the board. We also used this for specific bonuses to take on more shifts, or work weekends or overnights.

We used the ARPA funds for pay increases for staff. This helped with recruitment since we were able to increase the starting pay. This helped with retention if staff were leaving due to the pay.

These funds were used to provide hazard pay increases.

Relatedly, other types of compensation were often used to support recruitment and retention including providing PPE, paying for mileage or ride-shares, and meals.

Supporting our employees with enough PPE, healthcare, meals, paid time off, mental health and compassionate care were effective in retaining our employees.

Providers often reported use of ARPA stabilization payments to improve overall working conditions (e.g., flexible hours, allowing hybrid/remote work, tuition, or training reimbursements).

While there were many uses of ARPA funds to recruit DCWs, reports of the effectiveness of these approaches were mixed. Many providers reported minimally effective recruitment results.

We used Paycheck Protection Program (PPP), Cares Act and ARPA grants to supplement revenues to help retain and recruit. Unfortunately, current economic conditions have hindered our ability to keep pace with other industries for the same small pool of candidates who are looking for employment.

I cannot pinpoint any definitive strategies that actually worked.

Providers that focused on word-of-mouth recruitment strategies along with employee referral strategies and referral bonuses reported higher effectiveness.

Word of mouth worked best. We asked our staff to spread the word that we were hiring. This was our best method and worked moderately well.

Gave existing employees referral bonuses for referring people to apply and stay for 90 days. This did bring in new people that have stayed long term.

Monies spent advertising on recruiting sites were costly and mostly ineffective.

Retention strategies, most of which were tied to compensation, were more successful.

Stabilization funds were used to provide PPE for employees, base pay raise, bonuses, uniforms, education tuition payments, IT upgrade, Health Insurance, 401k, and [Federal Student Aid] FSA. It helped to retain the employees and to reduce turnover rate.

ARPA funds were extremely helpful in the retention of qualified and long-serving direct care staff. They remained on staff through COVID-19. It was not necessarily effective with recruitment of new staff.

Suggestions for Regulatory or Policy Changes

In addition to learning about and sharing successful strategies and best practices with all Medicaid HCBS providers, CT DSS’ second objective in fielding the survey was to seek suggestions for regulatory or policy changes (other than increasing rates or providing additional funds) that could be implemented at the state level to enhance providers’ ability to recruit and retain quality DCWs. Responses to that open-ended question were numerous and specific. (See Table 1 for a sample of detailed provider suggestions by category.) Many responses suggested ways the state could make caregiving itself more appealing as a career, since many do not view it as such. Specifically, since recruiting staff for limited or uncertain hours is difficult, providers recommended that caregivers’ authorized and approved hours be increased to a minimum of 20 hours weekly to make caregiver positions more appealing and improve retention.

Table 1.

Provider Suggestions for Regulatory and Policy Changes.

1	Make caregiving more appealing as a career
	The only way to improve this situation is to provide better opportunities for a long-term career… Right now caregiving does not feel like a career, so most people do not view it as a long term opportunity
2	Increase hours
	Caregivers prefer longer hours vs 2–3-h shifts
	We believe that in order to recruit and retain caregivers, new intake (client referrals) should start off with at least 20 hours a week (Part-Time) to recruit and retain caregivers. This would help decrease our turnover drastically
	Some clients want the same caregiver to provide all of the hours in their service plan, [but] because the state does not pay the agencies overtime, a second sometimes even a third caregiver is needed, and clients are not happy with these arrangements
3	Reduce documentation requirements
	The onboarding process is too long. The state requirements are too much. We are doing too many background checks and one of the background checks is very expensive when we could be using one online
	The amount of documentation is [the] primary reason staff leave Home Care. It is also a detriment to recruiting new staff
4	Loosen educational and experience requirements
	…develop a certification program for people without degrees specifically for our population. We feel people who work as patient care techs, home health aides would do well with our adults we serve if there was formal training
	Changing the ratios to decrease individual staff workloads would help immensely in retention of staff because it would decrease staff burnout
5	Enhance training opportunities
	The state could potentially implement a tuition reimbursement program (full or partial) to students who would like to pursue LPN/RN/CNA/HHA degrees or certifications. Or companies that offer tuition reimbursement for those degrees or certifications can be given a tax credit (or reimbursement stipend) for the value of the tuition reimbursement provided to employees
	Nursing schools have to have greater capacity to accept and train nursing students. Partner with employers to create pipelines to education while allowing employees to continue to work—create manageable ladders for CNAs to move to nursing
	It would be very helpful if there was an online aide training course approved by the State…that was available to home health agencies to use in order to certify their own health aides and increase this pool of workers
6	Revise unemployment benefits
	Regulate the unemployment benefits better to actually ensure that people are really looking for work, because we noted many people apply yet they don’t show up for interviews
	Assess the extensions provided under unemployment laws that were put in place during the pandemic. Some applicants are applying just to show they are seeking employment but not to work
7	Promote marketing
	Amen for addressing this question—the caregiving profession should be popularized by our government (social media, TV, stories, radio, local channels, and classes in schools)
	Offer platforms to promote our programs as career opportunities, for recruitment, and ways to connect with those entering the health fields
8	Support technology utilization
	Technology capacity building for employee relations and recruiting—supporting more virtual job fairs
	The state could develop a data base for direct care workers seeking employment so that providers would be able to have a larger hiring pool which could help raise recruitment rates. Additionally, there could be a database for employers to post open positions
9	Promote cross-agency collaboration
	Consider working with other state agencies to determine similar funding rates. It is very challenging to have contracts with multiple state agencies and have similar expectations but very different rates
	The state should also consider full privatization of direct support services like many other states have done so we are not competing for the same staff and resources
10	Other recommendations
	A childcare credit for healthcare workers would be a wonderful incentive that the state can offer to entice direct care staff to remain employed with their agencies
	Mileage reimbursement. 99% of our clients refuse to use a med cab. Furthermore, in more rural areas a round trip to the grocery store can exceed 15 miles. It is difficult for direct care workers to absorb that cost. If they have multiple clients in their case load, accessing groceries for their clients can exceed 100 miles per week
	Offer for HCBS providers to join in the state health insurance program to offer enhanced benefits

Providers also suggested that documentation requirements for integrating new employees are too burdensome and that reducing them is essential for recruitment and retention. They recommended loosening the educational and experience requirements for in-home staff positions, offering a certification program for people without a degree, and increasing minimum staffing ratios as additional ways to interest people in DCW jobs. Training suggestions included a tuition reimbursement program for students interested in home healthcare, online training opportunities, and addressing the scarcity of training facilities for nurses and other homecare workers.

Consistent with their frustration that enhanced unemployment benefits during the pandemic were detrimental to recruiting and retaining DCWs, many providers strongly advised the state to revise its unemployment benefits policy to incentivize working and remaining employed. They proposed a variety of ways the state could assist in marketing DCW careers through new and creative channels. They also made numerous suggestions related to technology improvements at the state level that would assist in recruiting and retaining DCWs, including virtual job fairs and a state registry of DCWs seeking employment. They emphasized the need for cross-agency collaboration to address the issue of unequal funding rates for DCWs between agencies.

Although providers were asked for recommendations that did not require rate increases or additional funding, some suggestions that involve increased state expense point out important issues with DCW work and are worth noting. These include childcare credits, mileage reimbursement, and benefits assistance. Childcare, a consistent problem for DCWs, was exacerbated by the pandemic. DCWs are often required to transport clients in their personal vehicles without mileage reimbursement. And nonprofit agencies have difficulty providing health insurance and other benefits that allow them to compete with the private sector.

Discussion

The growth in the number of older American adults (those aged 65+ will increase by two-thirds and those aged 85+ will nearly triple from 2020 to 2060) is driving higher demand for DCWs (PHI, 2023). Increasing use of HCBS as an alternative to institutionalization meets government policy and financial goals as well as personal care preferences (PHI, 2023), but is severely challenged by shortages of DCWs. Quantitative and qualitative evidence from Connecticut’s 2023 Medicaid provider survey confirms research findings that longstanding DCW recruitment and retention issues were exacerbated by the pandemic (Scales, 2021). Many providers reported that turnover increased by more than 50% compared to pre-pandemic levels, and that recruiting new DCWs was hindered not only by understandable COVID-19 concerns but also by decreased applicant quality, increased competition from other employers, and unintended consequences of government unemployment policy. Responses from hundreds of Medicaid HCBS providers offer insight into causes of recruiting and retention challenges, effectiveness of governmental initiatives, and ideas for longer-term effective strategies.

While longstanding issues of low pay and working conditions remained salient during the pandemic, candidate quality in many cases deteriorated. This may be due in part to increased competition from other industries. Talented lower wage workers were recruited heavily by non-healthcare employers such as grocery stores and warehouses, which offered higher wages and lower COVID-19 exposure. Nurses were recruited away from HCBS by hospitals and traveling organizations. Providers also reported that numerous employees left the workforce entirely or refused to seek new employment because enhanced unemployment benefits allowed them to make more money, lessen COVID-19 exposure, and remain with home-schooled children.

ARPA funds were designed in part to stabilize HCBS providers by enhancing their recruiting and retention efforts. Providers overwhelmingly reported use of these funds for compensation-related items: primarily increased pay or bonuses, but also training, meals, paid time off, or mileage reimbursement. Increased compensation was reported as somewhat effective in retaining employees, but far less so in recruiting new ones. More effective for recruiting were bonuses for existing workers who referred new employees. Increased funding for advertising and job boards was deemed mostly ineffective. Although ARPA funding provided the intended relief to many providers during the pandemic, those one-time funds are unsustainable and insufficient to stabilize the DCW workforce and sustain long-term HCBS growth.

Similar to the recent findings of a study of home care workers in New York (Tsui et al., 2024), COVID-19 created staffing issues for Connecticut providers but also offered opportunities to utilize creative strategies learned during the pandemic for DCW recruiting and retention, which were helpful and worth retaining. While increased compensation from state Medicaid programs may be difficult to obtain, offering weekly pay periods to DCWs who often live paycheck-to-paycheck proved popular, helpful to family budgeting, and a good recruiting and retention tool. A supportive organizational culture was also mentioned frequently as enhancing DCW retention, particularly one that emphasizes company values and ethical practices. Other appealing aspects of company culture that attract DCWs are good communication, employee wellness and recognition events, flexible scheduling, mentorship programs, and establishment of defined career paths and opportunities for advancement. One recruiting strategy that proved particularly effective for many providers was word-of-mouth: existing employees familiar with the company, culture, and job demands reaching out to friends or family who would fit in that environment. Online tools for recruiting, onboarding, and training also worked moderately well.

Other than rate increases, of particular consequence were providers’ recommendations to the state for regulatory or policy changes that would enhance their ability to recruit and retain DCWs. Consistent with pre-COVID research on the role of autonomy, control, and scope of practice in enhancing DCW careers (Gleason et al., 2023), an overarching theme of provider responses was that efforts should focus on making direct care work more appealing as a long-term career. Post-COVID research also noted that approaches to strengthening DCW roles outside of compensation should include increased training and expanding career ladders (Blum & Mathis, 2021). To further professionalism, a joint endeavor of the state and its provider network could offer additional training, tuition reimbursement, advanced certificate programs, and career pathways. They could also revisit shift availability and stability, hours worked, and overtime that prove problematic for DCWs. At the same time, providers suggested making direct care work more appealing to a broader segment of the population by decreasing educational and experience requirements and seeking non-traditional candidates such as retired persons and college students. Most important, messaging around direct care work should emphasize professionalism and an ethical and supportive culture.

Additional policy/regulatory changes suggested included revisiting burdensome regulations on hours, overtime, and mileage reimbursement, and streamlining background checks. Recommendations for enhancing technology, for example to create online registries and databases for providers seeking employees and DCWs seeking employment, are in line with recent research finding that COVID acted as a catalyst for adoption of new technology to increase DCW job quality (Bandini et al., 2023). In addition, providers suggested that more cross-agency collaboration would avoid issues of different agencies paying different rates for the same work. Providers also strongly advised government to revisit unemployment benefits policy to include incentives to work and remain employed. Recommendations made by Connecticut providers are similar to those made by Think Tank experts in the Office of Disability Employment Policy/LEAD Center (2022) and participants in the Centers for Medicare & Medicaid Services (2022) Direct Service Workforce Learning Collaborative, whose primary recommendations include professionalization of direct care work, enhancement of wages and benefits, and implementation of statewide direct care services training.

This study has some limitations. It summarizes experiences from only one state’s provider network, which may differ from other states’ ARPA policies and provider experiences. It includes more than one respondent from some providers. Organizations vary greatly in size: some are large and multifaceted, and responses may have diverged to some degree even within the same organization. Detailed information about each organization’s size, profit status, and services offered was not collected, which would be useful in future research.

While the one-time ARPA funds were beneficial during the pandemic and accomplished at least some of the state’s policy goals, they are insufficient to stabilize the direct care workforce and sustain the long-term HCBS growth required to meet the needs of an aging America. Many established themes from the DCW literature were confirmed, while lack of progress over the decades of longstanding recommendations made the pandemic disruptions more challenging. Nevertheless, lessons learned from the pandemic experience indicate that with creativity and focused attention, policy recommendations in the “standard playbook” for enhancing the DCW workforce, which have been consistently promulgated by advocates and thought leaders for over two decades (Scales, 2002; Stone, 2004), can bear fruit. A combination of greater financial investment, technology, and regulatory changes can make DCW jobs more attractive and enhance providers’ ability to recruit and retain a quality workforce. In addition, under the unique and unprecedented circumstances of the pandemic, front line providers found at least some success with innovative strategies that are not part of the standard playbook.

ORCID iDs

Julie Robison https://orcid.org/0000-0002-1787-9045

Kathy Kellett https://orcid.org/0000-0002-6748-5239

Deborah Migneault https://orcid.org/0009-0007-8570-1875

Noreen Shugrue https://orcid.org/0000-0003-2702-2683

Infographic