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A synthesis of direct service workforce
demographics and challenges across intellectual/
developmental disabilities, aging, physical
disabilities, and behavioral health
November, 2008
Prepared by —
National Direct Service Workforce Resource Center
http://www.dswresourcecenter.org
Research and Training Center on Community Living,
Institute on Community Integration, University of Minnesota
PHI
The Annapolis Coalition on the Behavioral Health Workforce
Printed November, 2008
Preparation of this document was funded by the Centers for Medicaid and
Medicare Services, Contract #TLG05-034-2967 to The Lewin Group. It was
also supported, in part, by Grant #H133B031116 from the National Institute
on Disability and Rehabilitation Research, U.S. Department of Education. This
document does not necessarily reflect the official positions of any funding
agency.
Citation:
The Lewin Group. (2008). A synthesis of direct service workforce
demographics and challenges across intellectual/developmental disabilities,
aging, physical disabilities and behavioral health. Washington, DC: Author.
Contents
Introduction and purpose / p.1
The direct service workforce / p. 2
Direct service worker roles and occupational titles / p. 2
Employment locations for DSWs / p. 3
Demographics of DSWs / p. 4
Evolution of support and service models along with guiding
principles of direct service work / p. 6
Behavioral health / p. 6
Aging and physical disabilities / p. 6
Intellectual and developmental disabilities / p. 7
Codes of ethical standards / p. 7
Direct service workforce challenges / p. 9
The status and image direct service workers / p. 9
Supply and demand conditions for DSWs / p. 9
Recruitment and vacancies / p. 10
Turnover of DSWs / p. 11
Turnover rates / p. 11
Challenges in measuring turnover / p. 11
Factors associated with DSW turnover / p. 12
Wages and benefits / p. 14
DSW wages / p. 14
Benefits: Access and utilization / p. 14
Public assistance / p. 15
Worker injury and employee assistance / p. 15
Training and education / p. 15
Identified DSW competencies / p. 16
Federal and state training requirements for DSWs / p. 18
Aging and physical disabilities / p. 18
Intellectual and developmental disabilities / p. 19
Behavioral health / p. 20
DSW career paths / p. 20
Behavioral health / p. 21
Aging and physical disabilities / p. 21
Intellectual and developmental disabilities / p. 21
Supervision of DSWs / p. 22
Workplace culture and respect for DSWs / p. 23
Self-direction / p. 24
Promising policies and approaches / p. 25
Improve DSW wages and access to benefits / p. 25
Reform training and credentialing systems / p. 26
Reform long-term care payment and procurement systems / p. 27
Engage the public workforce and education systems to support
recruitment and training of DSWs / p. 27
Design worker registries and other supportive resources / p. 27
Develop statewide stakeholder coalitions to develop and implement
state level workforce development plans / p. 28
Areas for planning and action / p. 29
Areas of focus / p. 29
Creating new partnerships and strengthening existing partnerships / p. 29
Education and training / p. 30
Recruitment and retention / p. 30
Wages, benefits, and rate structures / p. 31
Status and awareness / p. 32
Conclusion / p. 33
References / p. 34
Appendix A / p. 45
Community Support Skill Standards / p. 45
PHI competencies and skill standards for Direct Care Workers / p. 47
Certified psychiatric rehabilitation practitioner competencies / p. 48
Addiction counseling competencies / p. 48
Foundations / p. 49
Practice dimensions / p. 49
1
A synthesis of direct service workforce demographics and challenges across intellectual/
developmental disabilities, aging, physical disabilities, and behavioral health
Introduction and purpose
The Direct Service Worker Resource Center brings
together a consortium of leading workforce
development experts in the areas of aging, physical
disability, intellectual and developmental disabilities
and behavioral health to provide technical assistance
to states, organizations and individuals and to provide
support in addressing workforce challenges such as
recruitment, retention and training. Funded by the
Centers for Medicaid and Medicare (CMS) funded the
national Direct Service Workforce Resource Center
has worked intensively with 23 states, provided over
1,500 hours of general and approximately 3,700
hours of intensive technical assistance to states and
other interested entities. It has logged over 400,000
hits on its web site where users can access thousands
of documents regarding the workforce. This paper
provides an overview of direct service workforce
challenges and practices across four service sectors:
intellectual and developmental disabilities, aging,
physical disabilities and behavioral health. Another
DSW Resource Center national white paper addresses
data collection regarding workforce challenges across
service sectors.
The direct service workforce is highly fragmented.
This fragmentation is deeply rooted and r
eflects the
fact that each sector has its own funding, policy,
service and advocacy systems. One of the objectives
of the Direct Service Workforce Resource Center is
to provide an opportunity for researchers, educators,
practitioners, and policymakers to begin dialogue
regarding the similarities and differences of the direct
service workforce challenges and solutions and their
implications for practice and policy across sectors.
The purpose of this paper is to provide an overview
of direct service workfor
ce challenges and practices
across four sectors: intellectual and developmental
disabilities, aging, physical disabilities and behavioral
health. While much has been written and studied
within sectors about the workforce challenges
and solutions, this paper provides a synthesis of
the similarities and differences of the workforce
challenges and solutions across the sectors. Drawing
on the literature, activities and outcomes of the Direct
Service Workforce Resource Center since its inception
in 2005, the paper identifies the complexities of the
service sectors with respect to the workforce that
provides hands-on services and supports to people
who are aging, have disabilities, or experience
substance abuse issues. Another Direct Service
Workforce Resource Center white paper addresses
data collection regarding workforce challenges across
these four service sectors.
2
A synthesis of direct service workforce demographics and challenges across intellectual/
developmental disabilities, aging, physical disabilities, and behavioral health
The direct service workforce
Direct service worker roles
and occupational titles
Direct service workers (DSWs) are individuals who
receive monetary compensation to provide support
to individuals with a wide range of health and human
service needs. They pr
ovide hands on support to
individuals to assist them in living mor
e fulfilling,
independent, and self-directed lives. Supports
provided by DSWs vary depending on the type of
service setting in which they work. Identified roles
for DSWs across sectors include but are not limited to
activities such as —
Assisting with personal-care and hygiene such •
as bathing, dressing, and grooming;
Assisting with home skills such as meal planning •
and preparation, housekeeping, and budgeting;
Ensuring health and safety; •
Monitoring health; •
Providing health-related tasks such as medication •
management and administration, ileostomy,
colostomy
, and gastr
ostomy care);
Providing transportation; •
Providing employment supports;•
Implementing positive behavior support, crisis •
intervention;
Implementing recreation activities and •
supporting community involvement;
Conducting assessments and community •
referrals;
Teaching new skills (e.g., independent living, •
self-advocacy);
Supporting self-determination and self-direction •
of people served;
Working with family members;•
Providing opportunities for community •
integration; and
Providing companionship and support in •
developing, and maintaining social relationships.
There is not a single, unified occupational title
for DSWs in aging, physical disability
, behavioral
health, or intellectual and developmental disability
services. Occupational titles vary both within each
sector and acr
oss sectors. Previously these workers
were frequently referred to as “paraprofessionals”
because many did not have a formal post-secondary
education. However, in recent years this label has
become increasingly less popular across sectors
due to the recognized need for professionalism
(e.g., training, codes of ethics, worker-related
professional associations, and career paths, etc.) and
in recognition that in some health and human service
settings, DSWs have post-secondary education or
degrees.
In behavioral health a broadly recognized
occupational title to denote this work group does
not exist. T
itles are employer generated and there is
wide variability among employers, both across and
within geographic areas. As the role of people in
recovery as providers has increased, the term “peer
support specialist” has been more widely used. In
the intellectual and developmental disability (IDD)
service sector there are also many employer-derived
titles used to define the direct service workforce.
However, the title “Direct Support Professional” or
“DSP” is increasingly used by employers, advocacy
organizations, and in recent legislation passed by the
U.S. Congress. In aging and physical disability services
there are three commonly recognized categories
of job titles: “nurse aide,” “home health aide,”
and “personal care assistant.” In everyday practice,
workers in the third category are known by a variety
of names including “personal assistants,” “personal
care attendants,” “home-care aides,” and “home
attendants.”
3
A synthesis of direct service workforce demographics and challenges across intellectual/
developmental disabilities, aging, physical disabilities, and behavioral health
Employment locations for DSWs
DSWs are employed in a wide variety of settings.
They work in both institutional and community
services. Within community services they work in
residential, employment, individual and family homes,
and community treatment centers. Direct support is
both privately and publicly funded and provided in
both private for-profit and non-profit organizations.
Funding for these programs comes from a vast
array of federal, state, local and private funding
mechanisms, though Medicaid and Medicare are a
significant funding source.
Table 1 below shows the continuum of long term
care employment settings that ar
e common to most
DSWs.
Increasingly across all service sectors the
employment locations of DSWs are community based
and smaller in size. Supr
eme Court decisions such
as Olmstead v L.C. & E.H. as well as federal policy
efforts such as the New Freedom Initiative have
resulted in an increase in community services across
sectors. Deinstitutionalization has led to an increase
in the variety of different places in which people live
and has encouraged living arrangements for smaller
numbers of people.
This decentralization of home settings for
people who receive services has also led to gr
eater
geographic dispersion of the workforce. This
dispersion has led to direct service roles that require
greater skill, judgment and accountability and
that require greater autonomy, responsibility and
independent problem-solving and decision-making,
thus increasing the challenges faced by DSWs with
respect to receiving adequate supervision and having
opportunities for co-worker interaction.
Table 1. The continuum of long term care settings
Institutional settings Home- and community-based settings
Community
residential
Supports to
individuals & families
Non-residential
community supports
Nursing •
facility &
residential
rehabilitation
(e.g., SNFs,
ICFs)
State operated •
institutions &
large private
institutions
(e.g., ICF-MR,
residences
with 16 or
more people,
residential
rehabilitation,
psychiatric
hospitals, VA
hospitals,
residential
schools/colleges)
24-hr residential •
supports & services
(e.g., group home,
supported living
arrangement,
supervised living
facility, assisted living,
residential treatment)
Less than 24-hr •
residential supports
& services
(e.g., semi-
independent living
services, home-based/
family preservation)
Home health care •
services
Personal care •
services
(agency-directed)
Personal care •
services
(consumer directed)
Day programs, & •
rehabilitative or
medical supports
(e.g., day services
for seniors, MH
day services, adult
day programs,
rehabilitation for
working age adults,
outpatient treatment,
detoxification
programs,
methadone
treatment, homeless
shelters)
Job or vocational •
services
(e.g., supported
employment, work
crews, sheltered
workshops, job
training)
4
A synthesis of direct service workforce demographics and challenges across intellectual/
developmental disabilities, aging, physical disabilities, and behavioral health
Demographics of DSWs
National data about the direct service workforce is
not consistently available and reported across all
sectors inclusive of all DSWs. A national study of this
nature has never been completed. However, national
and state estimates of employment and wages for
a set of occupations containing the vast majority
of DSWs are available through the Occupational
Employment Statistics (OES) program, a federal-state
cooperative program between the Bureau of Labor
Statistics (BLS) and State Workforce Agencies that
conducts a semi-annual mail survey of employers. The
four occupations usually identified as being related
to the direct service workforce are: nursing aides,
orderlies and attendants; home health aides and
personal and home care aides; and psychiatric aides.
Within IDD the most recent national study of the
community DSW workforce was conducted in 1990
(Braddock et al, 1990). Since then state and local
studies of various sizes and levels of sophistication
have been used to identify the characteristics of
the workforce. The Residential Information Systems
Project provides national data on wages, turnover,
and full-time equivalent DSW staff ratios every two
years for DSWs in publicly funded institutions for
persons with IDD (Larson, Byun, Alba & Prouty, 2007).
While the OES estimates for direct-service
related occupations can be useful in suggesting
br
oad changes in state employment and wages for
several key DSW occupational categories, several
features of the underlying occupational and industry
classification schemes are problematic or confusing,
limiting the use of this data for workforce planning or
development purposes.
In particular, the occupational definitions are out
of date and mix DSWs with workers who provide
indir
ect services. Some of the industry classifications
such as “Residential Mental Retardation Facilities”
combine institutional and community long term care
services, reflecting an earlier era in which community-
based settings were the exception not the norm. In
addition, the reference to the range of populations
receiving services and supports could usefully be
made more explicit to include: older adults, people
living with intellectual, developmental, and physical
disabilities, and people with chronic mental illness or
addictive disorders. Finally, the OES counts of workers
do not include workers who are directly employed by
households or who are self-employed, leading to a
serious undercount of DSWs who work in home- and
community-based settings where consumer-directed
arrangements are the fastest growing mode of service
delivery.
While there are national data available for most
of the workforce, other non-national data sour
ces
exist as well. Many states conduct studies related
to this workforce and researchers have long been
reporting and synthesizing the data that do exist.
Table 2 provides an overview of what is known about
the demographics of the workforce across all four
sectors.
In addition to data obtained from ongoing
national/state surveys, some states have conducted
occasional studies related to this workfor
ce. Various
non-state entities such as provider trade associations
and university research institutions have long been
reporting the results of particular provider and worker
surveys. Table 2 provides an overview of the broad
demographic outlines of the workforce across all four
sectors.
The demographic make up of the direct service
workforce shows both similarities and dif
ferences
across sectors. In general, DSWs are typically women
in their 30s and 40s. The direct service workforce
in the aging and physical disabilities sector is more
diverse with regard to race and ethnicity. Within
intellectual and developmental disabilities there is
great variation across states regarding racial and
ethnic diversity among DSWs. Behavioral health and
IDD report higher proportions of DSWs with at least
some post-secondary education than does the aging
and physical disability sector. However, the available
behavioral health care data captures only a small
portion of DSWs in that field.
5
A synthesis of direct service workforce demographics and challenges across intellectual/
developmental disabilities, aging, physical disabilities, and behavioral health
DSWs are increasingly first generation Americans
and many have a first language other than English.
In some situations, these DSWs worked as health
care professionals (doctors, nurses and other
professionals) in their countries of origin and are
pursuing credentials to practice their profession in the
United States while working as DSWs. Organizations
employing DSWs report challenges related to the
increasing diversity of the workforce (e.g., age,
gender, race, ethnicity, language, religion, and
culture). As the demand for workers continues to
increase and more immigrant workers are employed
as DSWs, it will be important to have organizational
and community supports that offer effective training
and retention practices for these diverse workers.
Table 2. DSW demographics
Setting type Age Gender Race/ethnicity Foreign born Education
Nursing care facilities Median 36 91% F 49% white •
33% black •
11% Spanish, •
Hispanic or Latino
20% 54% high school •
education or less
66% high school •
education or less
58% high school •
education or less
Home health care
services
Median 44 91% F 41% white •
29% black •
22% Spanish, •
Hispanic or Latino
25%
Personal and home care 90% F
48% white •
23% black •
17% Spanish, •
Hispanic or Latino
Residential care facilities 75% F
Community residential
and vocational settings
32-39;
Median 35
66%-
99% F,
Median
81% F
59% white •
22% black •
8% Spanish, •
Hispanic or Latino
Increasing More than 50% •
some college
35% college •
degree
Psychosocial
rehabilitation
A
verage 38 65% F 70% white• Increasing 22% high school •
degree
13% some college•
38% college •
degree
Addictions 45-53 70% F 70-90% white•
Duffy, Wilk, West et al., 2006; NAADAC, 2003; Knudsen, Johnson, & Roman, 2003;
PHI, 2008; Larson, Hewitt & Knobloch, 2005
6
A synthesis of direct service workforce demographics and challenges across intellectual/
developmental disabilities, aging, physical disabilities, and behavioral health
Evolution of support and service models along
with guiding principles of direct service work
Many guiding principles and values have influenced
each service sector. Except for addictions, all have
historical roots in the medical model of service
delivery. All, except for addictions, are at various
stages of moving away from a model in which
doctors and medical personnel make all of the
decisions to a person-centered model in which the
individual service recipient acts as the primary director
of his or her own services. The extent to which
each service sector has aligned with the community
support model is described in the following
paragraphs.
Behavioral health
The workforce models within behavioral health have
had two distinct trajectories. In the field of addictions,
the foundations were in self-help, most notably
Alcoholics Anonymous (AA), and later Narcotics
Anonymous (NA). These self-help programs were
anchored by twelve action steps laid out by AA’s
founder Bill Wilson. For this reason the programs and
their many spin-offs are referred to as “twelve step”
programs. The AA tradition stressed anonymity and
volunteerism.
As the field has grown and as the science base
around pr
evention of and recovery from substance
use disorders has become more robust, the
workforce has changed as well. Originally heavily
oriented toward self-help and peer-supports, the
field has increasingly created more organized
social intervention models for which training
and credentialing are preferred or required. With
the acknowledgement that there are genetic
predispositions and physiological implications of
addictions (now recognized formally as illnesses
as opposed to a moral failing or negative habitual
behaviors) the field has gradually moved closer
to a more traditional medical or “professional”
model. That said, there remains a strong social-
systems orientation, and even such interventions as
detoxification are often conducted in non-medical
settings.
For treatment of mental health conditions, the
tradition has been strongly medical in orientation.
The field of psychiatry developed primarily in state
hospitals, and did not shift towar
d community-based
practice until after World War II. With this shift
away from institutions and augmented by a focus
on consumer rights and direction, the field is now
much more accommodating of a social-intervention
model. This change involves greater recognition of
the needs of the whole individual as the driving force
in treatment planning, as opposed to the much more
narrow focus on staff-driven efforts at symptom
reduction and management. The mental health field
has embraced the concept of recovery, a cornerstone
of treatment for substance use conditions, in the past
decade. As consumers have increasingly organized
and exercised leadership, self-direction and self-
advocacy have become more prevalent guiding
principles.
Aging and physical disabilities
Services for older adults and people with physical
disabilities increasingly focus on person-centered
approaches and self-direction. These principles first
appeared in relation to services for younger adults
with physical disabilities who were key leaders in the
civil rights movement for people with disabilities.
Self-direction and person-centered support have
long been an entrenched values in services to people
with physical disabilities. For younger people with
disabilities, the civil rights model that brought us the
Olmstead v. L.C. & E.H. decision has settled into a
self-direction approach for Home- and community-
based services. Self-direction has increasingly been
adopted throughout the aging services arena. While
the medical model remains a dominant model
7
A synthesis of direct service workforce demographics and challenges across intellectual/
developmental disabilities, aging, physical disabilities, and behavioral health
for elder services, particularly for services in large
congregate care settings, progressive standards
of care, as exemplified by the work of the Pioneer
Network, call for person-centered delivery of care
even within a medical setting. In addition, growing
numbers of older Americans rely on non-medical care
services delivered by independent providers who are
hired and directly supervised by the individual served
and/or his or her family.
Intellectual and developmental disabilities
In 2006 the President of the American Association
on Intellectual and Developmental Disabilities, a
physician, declared that the medical model no longer
drives how supports and services for persons with
IDD are delivered. Since the populations of public
institutions peaked in 1968, supports and services for
people with IDD have been transformed from being
based on hospitals and medical services to being
based in homes, jobs, communities and supports to
empower people with IDD to live fulfilled lives. The
number of people with IDD living in facilities with 16
or more people declined from 207,356 in 1977 to
only 62,496 in 2007 (Prouty, Alba & Lakin, 2008). In
2007, 501,489 individuals with IDD received supports
through the Medicaid Home- and Community-Based
Waiver program compared to 96,527 living in ICF-MR
settings and, 26,013 living in nursing homes.
Additional values and philosophies guiding the
field of intellectual and developmental disability
services include “self-determination,” “valued
social roles,” “inclusion and normalization.” Self-
determination is having access to opportunity and
r
esources to make one’s own decisions about life.
This is implemented through valuing the opportunity
for individuals with IDD to make their own decisions
in daily life from when they get out of bed, to who
they live with and what they eat for dinner. The
concepts of valued social roles center on the belief
that people with disabilities will be included in their
communities when they have valued roles in their
community. DSWs assist and support people with IDD
to have valued roles and to be included in activities
with people with and without disabilities. Lastly,
normalization is the principle that individuals with IDD
should live their lives with typical rhythms of the day,
month, week and year.
Codes of ethical standards
There is no universally accepted code of ethics for
DSWs across sectors. The purpose of a code of ethics
is to provide support and guidelines to practitioners
who are faced with decision-making and problem
solving responsibilities. A code of ethics provides
guidance to the worker regarding their behavior,
actions and attitudes as related to their professional
work. Because DSWs have been considered
“paraprofessionals” and have not historically had
professional affiliation and associations, it is not
surprising that there is not a universally accepted
code of ethics for DSWs across sectors.
Within behavioral health the National Association
of Addictions Professionals, which is a membership
organization and certification body for substance
abuse counselors, has adopted a code of ethics
comprised of nine principles addr
essing the following
topics: 1) non-discrimination, 2) client welfare, 3)
client relationship. 4) trustworthiness, 5) compliance
with law, 6) rights and duties, 7) dual relationships,
8) preventing harm, and 9) duty of care. This code
of ethics is required for all levels of employees in
the substance abuse field and was not specifically
designed for DSWs (http://naadac.org).
In mental health, the United States Psychiatric
Rehabilitation Association (USPRA) serves as a
member organization and certification body for
rehabilitation practitioners. Formerly the Inter
national
Association of Psychosocial Rehabilitation Services
(IAPSRS), this organization maintains a code of
ethics adopted in 2001 and built on core principles
addressing five areas: 1) the conduct of a psychiatric
practitioner, 2) psychiatric rehabilitation practitioner’s
ethical responsibility to people receiving services,
3) psychiatric rehabilitation practitioner’s ethical
responsibility to the profession, and 5) psychiatric
practitioner’s ethical responsibility to society (http://
www.uspra.org/i4a/pages/index.cfm?pageid=3361).
This code of ethics was also not designed specifically
8
A synthesis of direct service workforce demographics and challenges across intellectual/
developmental disabilities, aging, physical disabilities, and behavioral health
for DSWs but instead for all psychiatric rehabilitation
professionals, irrespective of their position or work.
The National Alliance for Direct Support
Professionals (NADSP) developed a code of ethics
for DSWs who are employed in community human
services. This code of ethics is intended for use by
all DSWs who work in community settings serving
people with a wide variety of human service needs.
NADSP’s Code of Ethics includes the following nine
principles that guide DSWs through the ethical
dilemmas they face daily and encourages the highest
professional ideals. These principles cover the
following nine areas: 1) person-centered support,
2) promoting physical and emotional well-being,
3) integrity and responsibility, 4) confidentiality,
5) justice, fairness and equity, 6) respect, 7)
relationships, 8) self-determination, and 9) advocacy
(http://www.nadsp.org).
Within the aging and physical disability sector
there is no known and widely accepted code of ethics
for DSWs such as nurse aides, home health aide
and/or for personal and home car
e aides. However,
considerable attention in the field has been focused
on a closely related matter: defining the quality of
care and identifying practical metrics to measure
the quality of care. This work began in nursing
facilities but has now been extended to home health
care services and beyond. Standard quality-of-care
measures range from indicators of care outcomes
(e.g., pressure sores, urinary incontinence, mortality,
and outcomes related to physical and psychosocial
functions) to use-of-service measures (e.g.,
emergency room visits and acute-care hospitalization)
to process-of-care measures (e.g., overuse of
restraints, use of urinary catheters, and frequency and
completeness of assessment). Analyses of quality of
care also sometimes incorporate measures of patient
and family satisfaction with services as well as the
incidence of complaints, violations, and deficiencies.
Unifying frameworks for articulating both the quality
of care for consumers and the quality of jobs for
DSWs recently have been proposed by PHI. See
http://phinational.org/what-we-do/advocacy/the-9-
elements-of-a-quality-job/
9
A synthesis of direct service workforce demographics and challenges across intellectual/
developmental disabilities, aging, physical disabilities, and behavioral health
Direct service workforce challenges
The status and image direct
service workers
There are high levels of societal stigma associated
with mental illnesses, addictions, intellectual and
developmental disabilities, disabilities in general, and
aging, so working with such individuals is too often
stigmatized as well. Together, relatively low wages
and benefits, minimal training, the absence of status,
clear role definition, and career pathways often create
the sense that DSW positions are low skill, dead end
jobs. While the significance of the DSWs’ role in the
provision of long-term care and community support
has become more recognized by professionals and
researchers, general public awareness of their role
is very limited, out of date, minimized or vilified. It
is not uncommon to see exposes on television or
negative articles about caregivers and DSWs in the
newspaper. The popular media rarely documents
stories about the importance of direct support
work, the contributions that DSWs make to their
communities and the positive outcomes that they
support people and families to achieve.
DSWs also face status and image problems
within their organizations. Employers often view
DSWs as interchangeable, easily r
eplaced, entry-
level workers on the lowest rung of the workforce
ladder. They are rarely in decision-making roles
and often carry out treatment plans, interventions,
program goals and orders from medical, nursing,
psychiatric, and other specialists. In addiction and
mental health services, DSWs who are in recovery
are almost always passionate and committed to
their work, but can experience the dual stigma of
having these illnesses and being entry-level workers.
NADSP has identified enhancing the status, image
and awareness of DSWs as a key guiding principle
and a goal of the association. Related goals for how
to improve the status and image of this workforce
include: 1) Providing better access for all DSWs
to high quality educational experiences (e.g., in-
service training, continuing and higher education)
and lifelong learning which enhances competency,
2) Strengthening the working relationships and
partnerships between DSWs, self-advocates, and
other consumer groups and families, 3) Promoting
systems reform that provides incentives for
educational experiences, increased compensation,
and access to career pathways for DSWs through
the promotion of policy initiatives (e.g., legislation,
funding, and practices) and 4) Supporting the
development and implementation of a national
voluntary credentialing process for DSWs.
Supply and demand conditions
for DSWs
The supply-side demographic with the most
substantial future implication for the direct service
workforce is the fact that the growth rate of the
overall workforce of working age females will
continue to level off for at least the next decade.
Female labor force participation rates peaked at the
end of the 1990safter years of rapid growth. The
potential supply of DSWs is also declining because
the baby boom generation is aging and retiring. In
fact, the overall national growth rate of working-
age females (aged 25 to 54) over the period 2006
to 2016 is expected to be negligible at one percent
(Toosi, November 2007). The direct service workforce
is also aging. As demands for new employees
increase and the pool from which new workers
can be recruited shrinks, the age of DSWs will also
likely increase. Many DSW positions require physical
strength and stamina. As the workforce ages,
proportionately fewer workers will be able to do
physical tasks sometimes associated with providing
supports for activities of daily living (especially lifting
and transferring). The use of assistive technology and
other strategies to reduce the physical demands of
the job for older workers will become essential.
The declining growth rate of the core female
labor supply contrasts with the economy’s booming
demand for DSWs. Accor
ding to the latest 2006
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A synthesis of direct service workforce demographics and challenges across intellectual/
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employment estimate for the DSW workforce from
the BLS, the current workforce surpasses the 3 million
mark and projected demand calls for an additional 1
million new positions by 2016. Personal and Home
Care Aides and Home Health Aides will be the second
and third fastest-growing occupations in the country
between 2006 and 2016, increasing by 51% and
49%, respectively. Moreover, personal and home
care aides, home health aides, and nursing aides,
orderlies and attendants are on the list of the top ten
occupations projected to register the largest numeric
job growth across the entire economy (PHI, April
2008).
A 2006 study indicated that in the field of
intellectual and developmental disabilities 900,000
new full time equivalent (FTE) DSWs will be needed
by the year 2020 (APSE, 2006). The demand for
new DSWs in behavioral health is unknown. While
direct-service work remains an occupation with
relatively few barriers to entry, this fundamental
supply side reality means that meeting the demand
for growing numbers of DSWs will require improving
the competitive attractiveness of DSW occupations,
particularly those in home- and community-based
settings.
Recruitment and vacancies
Current vacancy rates across sectors in direct
support positions are influenced by a number of
factors, including the demographic make up of
the direct service workforce, high rates of turnover
in direct support positions and increased demand
for community health and human services. Some
research has been done to understand the breadth
and depth of these challenges, although this research
varies by sector with the most limited completed
in behavioral health. Table 3 identifies a number of
studies and their key findings. There are no national
surveys of vacancy rates in home health care or home
and personal care, although there is considerable
Table 3. DSW vacancy rate information by sector
Study and key findings by sector
Larson & Hewitt, 2005
DSW vacancy rates in recent reports ranged from 0% to 33% depending upon position type, with a median
of 8% for all positions and 16% for part-time positions. The range for which DSW positions were vacant was
an average of 2.8 to10.5 weeks. Frontline Supervisors (FLSs) in residential settings reported that they offered
positions to 53% of all applicants (an indication of having very little choice in whom to hire; Larson et al., 1998).
In Kansas in 2003, 43% of administrators reported curtailing services to newcomers due to workforce challenges
(Kansans Mobilizing for Workforce Change Stakeholder Advisory Group, 2004).”
PHI National survey of state initiatives, 2007
97 percent of states responding reported that direct-service worker vacancies and/or turnover constituted
“a serious workforce issue.” This compares to 76 percent of states reporting a serious workforce problem
in the next to last survey, conducted in 2005.
AHCA nursing home study, 2003
CNA vacancy rate in 2002 was 8.5%, with state rates ranging from 3.6 to 16.7%. A vacancy rate of 8.5%
in 2002 translates into 52,000 vacant nursing assistant positions.
Hoge & Paris: Behavioral health literature review 1990–present, 2006
The literature on this topic is extremely limited and is focused principally on engaging minorities in graduate-level
training. There ar
e very few published articles on the recruitment of individuals into paid positions or volunteer
roles and, with few exceptions; this literature is essentially devoid of data.
There are frequent anecdotal reports of recruitment difficulties in behavioral health. Some of these are focused
on the problem of finding DSWs, although the complaints regarding recruitment are more often focused on the
graduate-degreed workforce.
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A synthesis of direct service workforce demographics and challenges across intellectual/
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anecdotal evidence that these rates are high enough
to be of serious concern.
The biggest obstacles to successful recruitment of
DSW workers in aging and physical disabilities are the
low quality of these jobs and their unattractiveness
relative to other jobs, many of which are less
demanding. Although many DSWs enjoy their chosen
field of work and find it rewarding, they experience
stressful working conditions, little career mobility,
and are among the lowest paid workers in the health
care and human services fields and in the economy at
large. In IDD, administrators report lack of qualified
applicants, inadequate pay and benefits, and
challenging hours as significant issues contributing to
their vacancy challenge Hewitt et al, 2000).
The economy’s booming demand for DSWs
only increases the challenge of how to make dir
ect
support jobs competitive so that they attract enough
workers to meet this increased demand. This is
especially important at a time when the growth in the
labor force is slowing significantly due to the aging
and retirement of the baby boom generation and
because the labor force participation rates of women
have finally peaked.
Turnover of DSWs
Turnover rates
High turnover rates among DSWs are widely known
and accepted by administrators, researchers and
advocates as a problem and a key barrier to the
delivery of quality services and supports in community
health and human services. While there is a growing
body of literature that explains turnover, the
availability of recent national studies that quantify
DSW turnover rates throughout the U.S. is scant.
Table 4 provides a snapshot of what is known
about the turnover rates across for DSWs across
sectors. It is important to note that the only national
study is AHCA, 2003. Other studies are limited in
scope to specific states or regions. All studies have
methodological limitations.
Challenges in measuring turnover
No comprehensive cross-sector national data on
DSW turnover exist (GAO, 2001). This is in part
because well-designed studies are costly and because
obtaining data across sectors is difficult. What data
do exist suggests that turnover, while generally
high for all DSWs, varies widely both within and
across various types of long-term care providers
(institutions, residential care, home care, assisted
living, etc.) and by geographic region. The lack of
uniformity in occupational titles and the vast array of
employment settings also complicate the process of
obtaining accurate national data. National surveys are
Table 4. DSW turnover across sectors
Sector/setting Source DSW turnover
Nursing facilities AHCA, 2003 71%
Home health Various studies 40–60%
Assisted living National Center for Assisted Living, 2001 40%
IDD in-home Hewitt and Larson 2007 — Review of 13 state
and 2 national studies between 2000 and 2007
65%
IDD residential 50%
IDD employment 69%
IDD multi-service 42%
Community mental health residential Ben-Dorr, 1994 50%
Addictions (not DSW specific) McLellan Craise & Kleber, 2003
Gallon, Gabriel & Knudsen, 2003
Exceeds 50%
25%
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A synthesis of direct service workforce demographics and challenges across intellectual/
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sometimes conducted and reported by national trade
associations within the various sectors where DSWs
are employed. Recently, the federal government
added new major national surveys of nursing
assistants and home health aides to two pre-existing
surveys. Preliminary data from the National Nursing
Assistant Survey is currently available at:
http://www.
cdc.gov/nchs/nnas2004.htm and data from the home
health aide survey is due out soon.
Because turnover is not calculated the same way
across surveys, the use of inconsistent measur
es
can make comparing turnover rates from different
studies problematic; turnover is not calculated the
same by all researchers. Barry, Kemper and Brannon
(2008) conclude “while these differences may reflect
differences in labor markets or state level policy,
they are also likely to result in part from inconsistent
methods in measuring turnover.” A 2004 report from
the Health Resources and Services Administration
outlined the need for more uniform approaches to
collecting turnover data for DSWs. In addition, a
recent national white paper from the DSW Resource
Center addressed state challenges concerning direct
service workforce data collection across service
sectors and proposed that states collect a “minimum
data set” of information on these workers across
settings, with turnover and vacancies being one of
six suggested elements for inclusion in the data set
(
http://DSWresourcecenter.org).
Factors associated with DSW turnover
Perhaps the greatest solution to the challenges
of vacancies is to solve the turnover problem.
Considerable research has been done to study the
factors that influence DSW turnover. Much of this
research has been conducted either in the aging
and physical disabilities sector or in the intellectual
and developmental disabilities sector and the
least has been completed in the behavioral health
sector. Most turnover studies have looked at single
factors associated with turnover but a few have
also conducted multivariate analyses (ASPE, 2006;
Dawson, 2007; Castle, 2007; Stearns & D’Arcy,
2008). There is also one study that was longitudinal
in nature (Larson, 1997).
The factors associated with DSW turnover can
be broken down into three basic vectors (Stearns
& D’Arcy, 2008): 1) personal demographic and
socioeconomic characteristics, 2) reported job
characteristics, and 3) other characteristics of the
facility and geographic area. In general, wages
and benefits are the two factors that have been
consistently identified in studies as factors associated
with higher rates of turnover for DSWs across the
IDD, aging, physical disability and behavioral health
sectors.
Factors associated with turnover in the general
human resour
ces literature have been examined
in several meta-analyses. Six factors were found
to be associated with higher turnover in more
than one meta-analytical study, low organizational
commitment, low overall job satisfaction, intent to
leave, low performance, and staff’s expectations
about the job not being met (Larson, Lakin &
Bruininks, 1997).
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A synthesis of direct service workforce demographics and challenges across intellectual/
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Table 5. Factors associated with DSW turnover across sectors
Personal demographic and socio-economic characteristics
Gender (A/PD)•
Race/ethnicity (A/PD)•
Age (A/PD)•
Marital status (A/PD)•
Children in household (A/PD)•
Citizenship (A/PD)•
Full-time work (A/PD)•
Commute (A/PD)•
Household income (A/PD)•
Education (A/PD)•
Reported job characteristics
Full-time hours if desired with stable work schedules, balanced workloads, and no mandatory overtime (A/PD)•
Wages (A/PD, IDD)•
Health insurance and other family-supportive benefits (BH, A/PD, IDD)•
Excellent training that helps the worker develop and hone skills (A/PD, IDD)•
Participation in decision-making (BH, A/PD, IDD)•
Non-financial incentives such as positive performance reviews and recognition (BH, IDD)•
Pleasant physical work environment (BH)•
Informal support from co-workers (IDD)•
Career advancement opportunities, professional challenge (BH, A/PD)•
Flexible work schedules (BH)•
Additional facility and area characteristics
Owners and managers willing to lead a participative, on-going “quality improvement” management system-•
strengthening the core support relationship between the consumer and the DSW (A/PD)
Linkages to organizational and community services, as well as to public benefits (A/PD)•
Supervisors who set clear expectations and require accountability, and at the same time encourage, support and •
guide each DSW (BH, A/PD, IDD)
Staff-to-consumer ratios (IDD, A/PD)•
Date program opened (longer the site was opened the lower the turnover) (IDD)•
Size of program site (smaller program sites had higher rates of turnover). (IDD)•
Geographic location (urban areas tended to have higher rates of turnover). (IDD, A/PD)•
Needs of people supported (organizations and sites that serve people with more intensive needs have higher •
rates of turnover). (IDD)
Live-in status (settings employing live-in workers had lower turnover) (IDD)•
Union status (IDD)•
Unemployment rates (areas with lower unemployment rates tended to have higher rates of turnover) (IDD, A/PD)•
* BH = Behavioral health; A/PD = Aging and physical disability; IDD = Intellectual and developmental disability
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A synthesis of direct service workforce demographics and challenges across intellectual/
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Wages and benefits
DSW wages
Wages and access to benefits are consistently
identified as strong predictors of DSW turnover.
Wages for this workforce are low. Table 6 identifies
DSW wages based on data obtained through the U.S.
Department of Labor (DOL) as well as other national
and state level studies.
Careers in direct support work often do not
provide livable wages. Low wages translate into low
family or household incomes. In 2006, just about
a quarter of DSWs employed in home health car
e
services lived in families with incomes under the
federal poverty level. This compares to 16 percent of
DSWs employed in nursing care facilities. Compared
to other low-wage jobs such as food preparation and
janitors and cleaners, a relatively high proportion of
DSWs live in families that earn under 200 percent of
the federal poverty level (PHI, 2008).
Benefits: Access and utilization
Employer provided health insurance is an important
factor related to finding and keeping DSWs
(Ebenstein, 2006). Most organizations offer health
insurance benefits to some of their DSWs but many
DSWs are not eligible to receive benefits because
they work part-time or on-call hours. Growing health
care costs have resulted in increased co-pays and
employee contributions which make insurance less
affordable to DSWs.
Table 6. DSW wages across sectors
Sector Data source Hourly
median
wage
Hourly
mean
wage
Hourly range
10
th
percentile to 90
th
percentile
Nurse aides U.S. DOL, 2007 11.14 11.50 8.10–15.52
Home health aides 9.62 10.03 7.41–13.47
Personal and home care aides 8.89 09.11 6.34–12.01
Institutional Polister et al, 2003;
Larson et al, 2007
11.67
13.17
Community residential and vocational Polister et al, 2003 08.68
Substance abuse counselors (not limited to,
but inclusive of, DSWs)
Kaplan, 2003
Johnson and
Roman, 2002
13.71
16.41
Research in the aging and physical disability
sector describes access and utilization of benefits
for DSWs in that sector. However, little is known in
behavioral health specifically related to DSW benefits.
Employee benefits offered to DSWs decline on the
provider continuum as workers move from positions
in institutional care toward community care and
home care. Although most providers contribute
some amount to employee health insurance for
full-time DSWs, the amount paid by community-
based providers is less than the amount paid by
large institutional or state run programs. Similarly,
paid vacation and sick leave decrease along the
continuum. Across sectors there is more information
and research in the aging and physical disability
sector about access and utilization of benefits for
DSW; little is known in behavioral health specifically
related to DSW benefits.
Data from the 2007 Current Population Survey
indicate that 43.1% of DSWs who were employed
by home health car
e services did not have health
insurance coverage in 2006. This compares with 25.8
percent of DSWs in nursing care facilities (PHI, 2008).
Employer-sponsored insurance (ESI) varies greatly
between nursing facilities and home and residential
care providers. The Hospital and Healthcare
Compensation Service (HCS) publishes annual salary
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A synthesis of direct service workforce demographics and challenges across intellectual/
developmental disabilities, aging, physical disabilities, and behavioral health
and benefits reports for both nursing homes and
home care, and their latest report indicates that
nearly all (99.9%) nursing homes and home care
agencies offer a health care benefit program (HCS,
July 2007). Several state-specific studies found lower
levels (e.g., Minnesota Department of Health found
that only 81% of long-term care facilities surveyed
offered health insurance — Minnesota Department of
Health, 2002). PHI’s analysis of CPS data found that
52.4% of all direct care workers have ESI, with 57%
of nursing and home health facility workers receiving
ESI but only 42% of personal and home care workers
(PHI, 2008). Those workers employed directly by
individual households clearly fare much worse.
Industry data from HCS indicates that nursing
home employers pay on average 76% of the
insurance premium for individual coverage, with
home care agencies paying approximately 74%.
Many state studies have found a lower contribution
paid by the employer. National data on take-up rates
for employer-supported insurance by DSWs is not
available, but studies both on this sector and low
wage workers overall find that if workers have to pay
more than 5% of their income for health insurance,
they do not take it. Even when they do, often plans
have high co-pays and deductibles which create
additional barriers to seeking care when needed.
With average wages of under $10 per hour, and
average annual insurance premiums of $4,500 for
individuals, most direct care workers cannot afford
coverage without significant subsidies or employer
contributions. In Minnesota (MDH, 2002) there was a
68% take-up rate for eligible employees and a total
of 36% of employees enrolled. A 2004 cross industry
study showed that only 41% of employed adults
earning less than $10 an hour qualified for employer
sponsored health care insurance for the entire year
compared with 72% of adults earning $10 to $15
per hour and 88% of adults earning more than $15
per hour (Collins et al., 2004).
After health insurance, probably the two most
important benefits are paid sick days and other paid
time of
f. The information available on these two
benefits is extremely limited. One estimate comes
from IWPR 2007 which found that in 2006, of full-
time DSWs, 55% of personal and home care aides
and 35% of nursing, home health and psychiatric
aides were not offered sick days in 2006 (IWPR,
2007).
Public assistance
A high proportion of DSW households rely on some
form of public assistance in order to make ends
meet. This assistance can be found in the form of
food assistance, cash assistance, housing assistance,
transportation and energy assistance, public
health care and/or Medicaid. In 2007, 42 percent
of all DSWs (as captured by the CPS occupational
categories “Nursing, Psychiatric and Home Health
Aides; and Personal and Home Care Aides) lived in
households that relied on some kind
of public assistance (PHI, 2008).
Worker injury and employee assistance
Work-related injuries are common in direct support
work. According to the latest Survey of Occupational
Injuries and Illnesses in 2006, the nursing aide
occupation had the highest incidence rate of injuries
and illnesses of any occupation. These rates exceeded
those of construction laborers, tractor-trailer truck
drivers, roofers, and welders. All types of nursing
and residential care facilities reported injury and
illness rates that are 2 to 2.5 times those for service
producing industries in general (U.S. DOL, November
2007; PHI, 2007).
The Substance Abuse and Mental Health Services
Administration (2007) recently r
eported that, among
all workers in the U.S., personal care workers
experience the highest rates of depression lasting two
weeks or longer. Yet, most DSWs do not have access
to employer funded employee assistance and health
insurance benefits that include mental health services.
Training and education
While DSWs spend more time with individuals who
receive long term care and human services than
other degreed professionals, they receive the least
amount of training and have the least education.
The delivery of training and education to DSWs is an
16
A synthesis of direct service workforce demographics and challenges across intellectual/
developmental disabilities, aging, physical disabilities, and behavioral health
increasing challenge across service sectors. With the
exception of CNA and HHA programs, there are few
state required or employer-based pre-service training
programs for this group of workers. Most DSWs rely
solely on employer developed and delivered training
post hire. As services become more geographically
dispersed, the ability to get workers to training is
more difficult and costly for their employers. In many
states and organizations workers are not reimbursed
for mileage and some are not paid to attend training.
DSW training is also difficult because often it is
driven by regulations concerning a training hour-level
requirement rather than being competency based.
In other words, new workers are required to have
a certain amount of training on specific topics and
they are told they have to get training because of
regulations. Training is often a mandated minimum
instead of individually focused staff development. This
regulatory-driven culture of training results in DSWs
who are not trained to develop the competencies
they need to do the job but instead complete seat
time on required topics. Additionally, most of these
training regulations are outdated or are non-existent
for certain groups of DSWs. Wide variation exists,
with the better training programs often going beyond
the minimum hours required by federal or state law
and others providing only the minimum or close to
the minimum number of hours.
Identified DSW competencies
Each DSW service sector has separately addressed
the training needs of the DSWs that work in sector-
specific settings. Varied methodologies were used
to identify the training needs of DSWs within each
sector. Methods have included: 1) the completion of
comprehensive national job analyses, 2) validation
studies, and 3) expert review and analyses. These
analytic activities assist policy makers and trainers
in developing curricula designed to advance
knowledge, skills and attitudes in the direct service
workforce. Post-secondary educators, employer
trainers, state-level policy makers and training and
development professionals have used these sets of
competencies to design training for DSWs in the U.S.
In depth descriptions of the following specific sets of
competencies are provided for review in Appendix A
of this paper: 1) Community Support Skills Standards
(community human services), 2) Community core
residential competencies (community residential in
IDD), 3) PHI competencies and skill standards for
direct-care workers (aging and physical disabilities),
4) Certified psychiatric rehabilitation practitioner
competencies (behavioral health), and 5) Addictions
counseling competencies; Foundations and practice
dimensions (behavioral health).
While each of the sets of competencies have
their own evolution and are used in many ways
within their respective sector, there are common
competencies across the sectors in which DSWs are
employed. Table 7 identifies some of these common
areas of competence. The dark shaded fields are
those in which there was overlap in three or more
of the sets for that specific competency area. This
is intended to show that there is clear overlap.
However, until a thoughtful and comprehensive job
analysis is completed across sectors, it is not possible
17
A synthesis of direct service workforce demographics and challenges across intellectual/
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to fully understand the common core competencies. Once these are identified, career pathways that build from
the core competencies could be developed and implemented.
Table 7: Common core competencies for DSWs across sectors
Competency areas*
DSW competency sets by sector
Intellectual and
developmental
disabilities (CRCC)
Community human
services (CSSS)
Substance
abuse (addiction
counseling
competencies)
Mental health
(CPRP)
Aging and physical
disabilities (PHI)
Household
management
Community living
supports and skills
Facilitation of services Facilitation of services Service coordination;
Treatment planning
Health and wellness Understanding
addiction;
Treatment knowledge
Personal care skills;
Health related tasks;
Infection control;
In home and
nutritional support;
Self care
Organizational
participation
Organization
participation
Diversity Role of the direct care
worker
Documentation Documentation Documentation
Consumer
empowerment
Participant
empowerment
Counseling System competency
Assessment Assessment Clinical evaluation;
Applications to
practice
Assessment, planning,
and outcomes
Apply knowledge
to the needs of the
consumer
Advocacy Advocacy Professional and
ethical responsibilities
Consumer rights,
ethics, and
confidentiality
Community and
service networking
Community and
service networking
Referral Community resources;
System competency
Building and
maintaining
friendships and
relationships
Communication Communication Client, family, and
communication
education
Interpersonal
competency
Communication,
problem solving, and
relationship skills
Crisis intervention Crisis intervention Interventions Safety and
emergencies
Professionalism Education, training,
and staff development
Professional readiness Professional role
competency
Vocational, education,
and career supports
Vocational, education,
and career supports
* Dark shading indicates competency areas where three or more sets identified similar competencies have been
identified
18
A synthesis of direct service workforce demographics and challenges across intellectual/
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Federal and state training
requirements for DSWs
Federal and state training regulations and
requirements for DSWs vary by sector and the
specific service type (and related funding) in which
DSWs are employed. In general, the more restrictive
and institutional the service is, the greater the
requirements and regulations. Aging and physical
disability services tend to have the greatest number of
federal regulations. In intellectual and developmental
disabilities, training requirements for services other
than ICF/MR are left to the states and in behavioral
health, there are no uniform mandatory training
requirements for DSWs.
Aging and physical disabilities
Federal regulations require initial and ongoing
training for DSWs who work as home health aides in
certified home health agencies or as certified nurse
assistants (CNAs) in Medicare- and/or Medicaid-
certified nursing homes. These workers must
demonstrate competency in specific areas and are
required to have at least 75 hours of instruction, 16
of which involve practicing hands-on “clinical tasks”
under the direct supervision of a nurse and prior to
direct contact with a resident or patient (PHI, 2005).
Federal regulations also require that both CNAs and
home health aides receive a minimum of 12 hours of
in-service training during each 12-month period, but
the regulations offer little guidance as to what must
be taught.
For CNAs, basic training must cover various
subjects that address communication and
interpersonal skills, infection contr
ol, safety and
emergency procedures, and promoting residents’
independence and rights. Other required topics that
must be included in the training curriculum include:
1) Basic nursing skills, 2) Personal care skills, 3)
Mental health and social service needs, 4) Care of
cognitively impaired residents, 5) Basic restorative
services (e.g., training the resident in self-care or use
of assistive devices) and 5) Resident rights.
CNA curricula must be state-approved, but
there is no limit to how many pr
ograms a state
may approve. As of 2002, about half of states had
established a single approved curriculum; others
have approved more than 100. Based on state-
reported information, the OIG estimated that as of
2002 there were more than 12,500 state-approved
nurse aide training programs in the United States,
with approximately 60% (or 7,500) facility-based
nurse aide training programs, primarily sponsored by
nursing homes with classroom instruction held in the
nursing facility. These programs are designed to assist
nursing facilities with recruitment and to facilitate
training for new hires that may undergo training
in the facility in which they will be employed. The
remaining 40% (or 5,000) non-facility based training
programs were held in high schools, vocational-
technical schools, community colleges, and private
schools. Some programs were sponsored by non-
profit organizations such as the American Red Cross,
others were sponsored by labor unions or affiliated
with government welfare-to-work programs or other
government entities such as the Department of
Veterans Affairs (DHHS, 2002).
About half the states go beyond these minimum
federal training requir
ements for CNAs (AARP 2006).
The more rigorous training requirements reflect the
concern that the 75-hour federal minimum may not
be sufficient to prepare CNAs to provide good care
to residents, given that the complexity of caring for
nursing home residents has increased since federal
training requirements were established with the
passage of the 1987 Nursing Home Reform Act. In
addition, many training programs provide more hours
required by federal or state law, because program
directors do not believe that the required topics
can be adequately covered without additional time.
Other training programs, however, provide only the
minimum or close to the minimum required number
of hours.
Federal requirements for home health care aide
training indicate that participating agencies must
address the following twelve subject ar
eas: 1)
Communication skills, 2) Observation, reporting,
and documentation of patient status and the care
or services furnished, 3) Reading and recording
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A synthesis of direct service workforce demographics and challenges across intellectual/
developmental disabilities, aging, physical disabilities, and behavioral health
vital signs, 4) Basic infection control procedures, 5)
Basic elements of body functioning and changes
in body function, 6) Maintenance of a clean,
safe, and healthy environment, 7) Recognition of
and procedures for emergencies, 8) The physical,
emotional, and developmental characteristics of
the patients served and patient privacy, 9) Personal
hygiene and grooming, 10) Safe transfer techniques
and ambulation, 11) Normal range of motion and
positioning and 12) Basic nutrition and fluid intake.
State laws and/or regulations generally follow the
federal requirements for training certified home
health aides. States that have established training
requirements for home health aides may be similar
to federal requirements or go beyond federal
requirements. For example, states may require more
training hours or require home health aides to
complete CNA training and certification in order to
provide home health services. According to PHI, 27
states and the District of Columbia already require
additional hours for CNA training beyond the federal
minimum requirement of 75 hours. In addition,
13 states and the District of Columbia require 120
hours or more, and five require 150 hours or more.
Depending on the training sponsor, the actual
amount of total training time can exceed the federal
and/or state minimum requirements.
There are no federal requirements related to
training personal care assistants (PCAs). For states
that offer Medicaid-funded personal care services,
the State Medicaid Manual (Chapter 4, Section 4480,
paragraph E) requires them to develop provider
qualifications for PCAs. The manual does not list
specific qualifications, but rather offers examples
of areas where states may establish requirements
including: 1) Criminal background checks or screens
for attendants before they are employed, 2) Training
for attendants, 3) Use of case managers to monitor
the competency of personal care providers, and 4)
Establishment of minimum requirements related to
age, health status, and/or education.
A 2006 report by the Office of the Inspector
General of the U.S. Department of Health and Human
Services (HHS, 2006) examined state requirements for
Medicaid-funded personal care services. The study
found that the majority of states (43) had established
multiple sets of requirements for Medicaid-funded
PCAs. More specifically, these requirements differed
across the different types of benefits within a state’s
Medicaid program (Medicaid state plan vs. Medicaid
waiver services) and/or the delivery models within
these types of Medicaid benefits (agency-directed
vs. consumer-directed). Overall, these differences
produced 301 sets of requirements for PCAs across
Medicaid programs in all 50 states and the District
of Columbia. Seven states had established uniform
requirements across their state Medicaid program.
According to the OIG report, 46 states
incorporated training requir
ements in at least one
Medicaid program offering personal care services.
However, variation in these requirements exist by
program and state in terms of the content, duration,
and time necessary to complete training. Only 45%
(or 102) of the 227 requirement sets that include
training specified the number of required training
hours, and the median number was 28. Subjects
covered in the training curricula include: 1) First aid or
cardiopulmonary resuscitation (CPR), 2) Basic health
(e.g., food and nutrition, hygiene), 3) Assistance
with activities of daily living, 4) Basic orientation
(e.g., beneficiary rights, safety, behavioral issues,
patient confidentiality), 5) Specific training related to
beneficiary’s needs and 6) Other training included in
the state-developed curriculum.
Intellectual and developmental disabilities
Training regulations and standards within the field
of IDD are not articulated in federal regulations. ICF/
MR standards require that a training program exists
for DSWs. This program must have the following
components: 1) The facility must provide each
employee with initial and continuing training that
enables the employee to perform his or her duties
effectively, efficiently, and competently; 2) For
employees who work with clients, training must focus
on skills and competencies directed toward clients’
developmental, behavioral, and health needs; 3) Staff
must be able to demonstrate the skills and techniques
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A synthesis of direct service workforce demographics and challenges across intellectual/
developmental disabilities, aging, physical disabilities, and behavioral health
necessary to administer interventions to manage the
inappropriate behavior of clients, and: 4) Staff must
be able to demonstrate the skills and techniques
necessary to implement the individual program plans
for each client for whom they are responsible. Many
states include additional state required training for
DSWs but this varies from state to state and national
data regarding variation across states does not exist.
Within the IDD sector most DSWs are employed
in Home- and community-based services because
this is the primary service type delivered to this
population. Currently CMS does not prescribe
training requirements under this program. However,
states must ensure provider qualifications for
providers receiving Medicaid funds. The reality
for DSWs is that they experience vastly different
orientation and training programs depending upon
the state in which they live and the organization
in which they are employed. Some states require
few if any training hours and others have rigorous
expectations. A common experience for DSWs would
be approximately 20–40 hours of initial training
delivered in the classroom based on topics such
as first aid, CPR, blood borne pathogens, HIPAA,
introduction to developmental disabilities and
medication administration. A national curriculum,
College of Direct Support, is now being used for
training DSWs statewide in 16 states and is used
daily by approximately 114,000 DSWs. While it is
predominately used in intellectual and developmental
disabilities, in a few states it is being used across
sectors (CDS, 2008).
Behavioral health
There are no federally mandated training
requirements for DSWs in behavioral health.
Standards from organizations such as the Joint
Commission on the Accreditation of Healthcare
Organizations (www.jcaho.org) or the Commission
on the Accreditation of Rehabilitation Facilities
(www.carf.org) mandate orientation and training
for all employees, although participation in the
accreditation process is voluntary. Workforce related
requirements in accreditation standards tend to be
general in nature, focusing on the need to ensure
that employees receive adequate training for their
functional duties, including safety related skills such
as infection control.
States typically license mental health and substance
abuse treatment facilities. Licensing standar
ds that
require adequate staffing and basic orientation and
training for staff typically cover DSWs who work in
these settings. However, such requirements tend not
to be highly prescriptive and do not target DSWs.
There is no standard curriculum used to train
mental health practitioners at any level of this
workforce. Many organizations have designed
such curricula, but none have become nationally
r
ecognized and widely adopted. A review focused
on competencies and curricula for mental health
DSWs did find promising models, though not widely
adopted (Stryon, Shaw, McDuffie, & Hoge, 2005).
Most training in substance use disorders treatment
is linked to the Addiction Counseling Competencies
(Center for Substance Abuse Tr
eatment, 2006).
However, training programs that teach the
competencies (knowledge, skills, and attitudes)
previously identified in this paper have not been
standardized (Morris, Goplerud, & Hoge, 2004).
Edmundson (2002) studied the 260 training programs
listed by NAADAC, the addiction counselors’
professional association. Fifty-five percent were at
the community college or two-year Associate level,
13% at the bachelor’s level, and 32% at the graduate
level.
DSW career paths
Well-established career paths for DSWs do not exist.
With only a few exceptions, those that do exist are
sector specific and are built around sector specific
competencies. These career paths are typically
not rooted pathways that move from pre-service
training to post-secondary degree programs. Instead,
these usually seek to move DSWs out of the role of
direct support and into supervisory or more clinical
positions.
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A synthesis of direct service workforce demographics and challenges across intellectual/
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Furthermore, few systemic incentives typically
are built into the career paths that do exist. Any
incentives usually have to be funded by organizations
that are already struggling to provide adequate
wages and access to benefits. Finally, it is extremely
unusual to find rate-setting mechanisms in place that
provide for increased wages and other incentives
for completing training tied to career paths. In sum,
a lack of incentives coupled with the rigor of the
required training hours and the costs associated with
training result in low completion rates for DSWs with
regard to career path training.
Behavioral health
Career paths for DSWs in behavioral health are most
robust in the area of addictions. Individuals without
prior experience or training can enter the workforce
as technicians in varied programs, such as residential
or methadone treatment facilities. There are
diverse educational opportunities available through
community and four year colleges and graduate
schools that qualify an individual for increasing levels
of state and national certification and state licensure.
Positions that require higher levels of certification and
licensure typically have higher salaries and benefits.
While this career ladder in addictions has many
positive features, salaries and benefits in this sector of
the behavioral health workforce are often considered
non-competitive, leading many individuals to leave
this career path for other pursuits.
The career ladder in mental health is strong for
those pursing graduate level training, but largely
absent for DSWs. Few community colleges offer
r
elevant training that fosters advancement, salary
enhancement, or certification for DSWs. The rungs of
the career ladder that might lead to certification or
licensure are largely missing. The Alaska Native Tribal
Health Consortium is pioneering a multi-tiered career
ladder for behavioral health aides that is built on the
“grow your own” principle (http://www.anthc.org/
cs/chs/behavioral/). However, such innovation in the
mental health field is rare.
Aging and physical disabilities
About one-fifth of states have implemented some
kind of state sanctioned or approved career ladder
and/or advancement programs for DSWs. In several
other states career path programs are under
consideration. Examples of these programs include:
state-adopted U.S. DOL apprenticeship programs for
CNAs, HHAs and Health Support Specialists (HSS) and
the establishment of specialty aide positions such as
medication aide, geriatric aide, nutrition assistant,
and, senior aide (PHI, 2008). These specialty positions
generally require advanced competency training and
certification.
Career paths for DSWs in aging and physical
disabilities are not well established in post-secondary
education pr
ograms. However, there are professions,
such as LPN and RN, with established education
programs in which CNAs, HHAs and HSSs could
matriculate.
Intellectual and developmental disabilities
Career paths in direct support for persons with
intellectual or developmental disabilities are rare and
within states that do have them, they are not widely
accessible and used by DSWs. Existing programs are
sometimes attached to post-secondary education
programs (e.g. ND, GA, IN) but often are provider
driven (e.g. OH, FL, WY). The U.S. DOL has federal
guidelines for the occupational title of Direct Support
Specialist, however only a handful of these programs
have been approved at the state level and completion
rates are low. Yet, there is an increasing awareness
among providers and advocacy associations that
career paths are perhaps one way to improve DSW
retention and justify increased wages for workers.
NADSP has developed a national credentialing
program for DSWs working in community human
services. This credentialing framework has been
used (or is currently being developed) in a few
states that have career paths for DSWs who work
in services to persons with IDD (e.g., OH, KS, IN,
NJ, CA, FL). The purpose of this credentialing
program is to provide national recognition for the
contributions and competence of DSWs who apply
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A synthesis of direct service workforce demographics and challenges across intellectual/
developmental disabilities, aging, physical disabilities, and behavioral health
for and meet the credentialing standards. NADSP’s
credentialing program affords DSWs the opportunity
to commit to the profession of direct support
through its three-tiered credential program. DSW
career paths begins with the Registration Level (DSP-
Registered). As a DSP-Registered, DSWs are eligible
to complete expert training in the key competencies
of empowerment, communication, planning, ethical
practice and advocacy to become a fully certified
DSW (DSP-Certified). The third level of NADSP
credentialing (DSP-Specialist) recognizes DSWs
who have obtained specialized training and have
demonstrated competence in providing specialized
support to individuals with disabilities in community
human services. In order to receive a DSP-Certified
or DSP-Specialist credential, DSWs must complete
an approved training program that offers training
on specific competencies in both related instruction
hours and on the job training. Currently, NADSP
has approved five existing curricula that meet the
education/training requirements of NADSP’s national
credential. Other educational programs can be
approved but an application, site review, and NADSP
review of curriculum must be conducted before
approval is granted.
The first accredited curriculum is the U.S. DOL
certified apprenticeship program for the occupational
title of Direct Support Specialist. Certified
apprenticeship programs that meet the federal
guidelines for Direct Support Specialist and have been
reviewed by NADSP are approved curricula. Another
accredited national curriculum is the College of Direct
Support (CDS). CDS is a multimedia, interactive web-
based curriculum. CDS curriculum is designed for
use in conjunction with employer-based training.
Three state or agency level programs have also been
accredited in Georgia, Ohio, and Minnesota. Any
employer, post-secondary program, or other entity
can apply to NADSP to have their programs reviewed
and accredited so their graduates can apply for the
national credential.
Supervision of DSWs
Supervisor tenure and the quality of supervision
are associated with DSW turnover. When DSWs
leave their positions, they often cite lack of or poor
supervision as one of the primary reasons they are
leaving (Larson, Lakin & Bruininks, 1997). Supervisors
have a powerful impact on the lives of DSWs. A
DSW’s relationship with his or her supervisor is often
the most influential factor in determining whether or
not she/he feels valued and respected in her work. It
is also key to job satisfaction and ability to adequately
provide support and care (Bowers et al., 2003;
Kopiec, 2000; Laninga, 2001; Noelker and Ejaz,
2001; Iowa Caregivers Association 2000).
There are many reasons for the lack of effective
supervisor training and effectiveness acr
oss sectors.
First, most supervisors in aging/physical disabilities
and behavioral health are clinical staff and in
intellectual and developmental disabilities they usually
are DSWs who have been promoted. Few supervisors
in these sectors have received formal education or
training on how to be effective supervisors. Secondly,
as services become less institutionally based,
supervisors do not work in close proximity with the
DSWs they supervise. In IDD services, it is increasingly
common for DSWs to be supervised by individuals
they rarely see.
Anecdotal reports provide compelling evidence
that the provision of supervision has declined
significantly in both the mental health and addiction
sectors of the behavioral health field (Hoge, Morris,
Daniels, et al., 2007). This is due principally to
incr
easing financial constraints in behavioral health
organizations. Recognition of the need to restore
supervision has been increasing over the past five
years, although progress has been minimal given
the absence of clear models for covering the costs
involved related to supervisee and supervisor
time. Evidence of the growing recognition of the
importance of supervision can be found in the recent
release of competency models for supervision in
the addiction sector (Center for Substance Abuse
Treatment, 2007) and in mental health (American
Board of Examiners in Clinical Social Work, 2004).
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A synthesis of direct service workforce demographics and challenges across intellectual/
developmental disabilities, aging, physical disabilities, and behavioral health
While recognition of the importance of effective
supervision has increased across sectors, planned and
well-executed training programs for supervisors are
not prevalent. However, key attributes of an effective
supervisor have been identified and include: 1) The
ability to listen attentively in order to understand the
perspective of the worker when a problem arises,
2) The ability to constructively present and address
problems, 3) The capacity to help workers develop
problem-solving skills, and 4) The ability to build
relationships with supervisees. One approach that
has been gaining support among long-term care
providers and nurse education programs is Coaching
Supervision (PHI, 2005). Coaching Supervision is an
approach to supervisory training that emphasizes the
supervisor’s role in working with DSWs to develop
problem-solving skills (Murphey, 2005). It teaches the
importance of supervisors setting clear expectations
and requiring accountability, and at the same time
encouraging, supporting, and guiding each DSW.
Specific competencies required of supervisors were
developed in Minnesota (Hewitt, Larson, Lakin, Sauer,
O’Nell, & Sedlezky, 2004) and validated in a national
study (Larson, Doljanac, Nord, Salmi, Hewitt & O’Nell,
2007). From this work, fourteen broad competency
areas were identified for supervisors including:
enhancing staff relations, providing and modeling
direct support, facilitating and supporting consumer
support networks, planning and monitoring
programs, managing personnel, leading training
and staff development activities, promoting public
relations, maintaining homes, vehicles, and property,
protecting health and safety, managing finances,
maintaining staff schedules and payroll, coordinating
vocational supports, coordinating policies,
procedures, and rule compliance, and performing
general office work.
Workplace culture and respect
for DSWs
Organizational culture can have a profound effect
on DSWS intent to stay in their jobs and their
overall job satisfaction, and therefore has an
important impact on turnover and retention. When
DSWs report positive views of their organizational
culture—experiencing high morale, teamwork,
and participation in decision-making—they report
higher levels of job satisfaction and organizational
commitment, and residents report greater
satisfaction. Greater DSW involvement in decision-
making and care planning is associated with lower
retention problems, fewer job vacancies, and
decreased turnover.
Specifically with regard to DSWs working
in nursing facilities, management and work
environment have been found to be associated with
nurse assistant satisfaction, loyalty
, and commitment.
The satisfaction of nurse aides with involvement
in decision-making and professional growth was
significantly related to better overall job satisfaction
and greater intent to stay in nursing home jobs.
The job satisfaction, loyalty, and commitment of
nursing assistants deepen when DSWs perceive that
supervisors care about them as people, appreciate
their work, evaluate them fairly, and communicate
with them on important matters. Nurse assistant
satisfaction and engagement were higher when the
style of management was participative (“managers
listened to and cared for their employees and helped
out in times of stress”) and when there was ongoing
quality improvement (“managers kept the workplace
safe, did not stint on tools and supplies, and trained
workers well to deal with difficult residents and
families”). Finally, how DSW ratings of the quality
of management and of their work environment
were found to be significantly correlated with the
way residents’ family members rated the residents’
quality of life, care, and services provided (Dawson,
2007; Sikorska-Simmons, 2005 and 2006; Leon et al.,
2001; Banaszak-Holl et al., 1996; Tellis-Nayak, 2007;
Parsons et al., 2003).
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A synthesis of direct service workforce demographics and challenges across intellectual/
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In a study of best practices in DSW workforce
development, NADSP and the Research and Training
Center on Community Living at the University of
Minnesota reported that organizations that excel
at DSW workforce development were ones that:
1) Were learning organizations, 2) Hae Executive
Directors/CEOs that relied on advice from DSWs and
knew who they were, 3) Made listening opportunities
where management met with DSWs a part of their
routine, 4) Had executive and management staff that
made it clear by modeling that they could and would
do direct service; 5) Decision-making authority was
given to DSWs and site level supervisors; and 6) Were
culturally competent (ANCOR, 2008)
Self-direction
Self-directed services are increasingly being offered
by states in aging/physical disabilities and intellectual
and developmental disabilities. This model provides
the opportunity for the individual with the disability
(sometimes in conjunction with family or other legal
representatives) to self-direct their services using
Medicaid funds. While increasingly identified as a
desirable approach in behavioral health, self-direction
in that sector has moved toward person-centered
planning, more consumer control over treatment
options and decision-making, peer support, and the
employment of persons in recovery in the behavioral
health workforce. Self direction is one solution to
increasing the pool of potential DSWs because often
persons in recovery, friends, and family can be hired
as employees.
The Consumer Direction of Personal Assistance
Services (CD-PAS) is one of the fastest gr
owing
programs under Medicaid Home- and Community-
Based Services, although a relatively small number of
Medicaid beneficiaries are currently enrolled in this
type of program model. In 2006, 42 states allowed
some form of self-direction. Within A/PD and IDD
there are three general models of self- direction use
by states to extend varying degrees of choice and
control to Medicaid beneficiaries over their personal
assistance services and supports.
Agency with choice.• These are programs that
provide services to the Medicaid beneficiary
. They
range from a traditional home health agency,
which assumes most of the responsibilities for
arranging services, to agencies that involve
Medicaid beneficiaries in arranging multiple
aspects of their personal assistance services.
Public authority.• These are programs that rely
on the Medicaid beneficiary to structure and
arrange who, when and how their personal
assistance services will be pr
ovided. The public
authority makes information regarding screened
individual providers available to the Medicaid
beneficiary.
Fiscal/employer agent.• These are programs
that typically rely on the Medicaid beneficiary
to assume the r
ole of the employer and the
responsibility for arranging most aspects of their
personal assistance and submitting information
to a fiscal agent that performs payroll functions
for the Medicaid beneficiary under contract
with the state. Individual budgets are typically
associated with Fiscal/Employer agent models of
consumer direction.
Within the public authority and fiscal/employer
agent models of self-direction, the vast majority
of dir
ect care workers are considered independent
providers. (In the agency with choice model, direct
care workers are typically employees of the agency
and not the individual). In these models, the DSW is
employed or, minimally, guided and directed by the
individual being served. Most self-directed programs
do not require workers to undertake any formal
training. However, an increasing number of states are
making training available to workers.
Another growing trend is state-supported training
and education provided to the service r
ecipient, and
his or her family on how to find, choose, hire and
keep DSWs. While initially individuals who self-direct
often rely on friends and family for staff, eventually,
if they receive services for extended periods of time,
these individuals may need to hire and retain more
traditional employees. Without effective support, this
can be a daunting task.
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A synthesis of direct service workforce demographics and challenges across intellectual/
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Promising policies and approaches
The pervasiveness of the challenges brought on by
the growing need to create an adequate, stable and
well-prepared direct service workforce has resulted in
numerous demonstrations and a growing emergence
of evidence based practices. Both states and provider
organizations are showing increased interest in and
responsiveness to the difficulties of finding, keeping
and training DSWs.
Emerging promising policies and practices are
clustered in several br
oad areas —
Improving DSW wages and access to benefits•
Reforming training and credentialing systems•
Reforming long-term care payment and •
procurement systems
Engaging the public workforce system to support •
the recruitment and training of DSWs
Designing worker registries and other resources•
Developing statewide stakeholder coalitions to •
develop and implement state-level workforce
development plans
These approaches are not necessarily occurring
across all sectors, but rather ar
e more likely to be
tied to a single service sector or group of provider
organizations. Much of the information below comes
from the results of the 2007 National Survey of
State Initiatives on the Long Term Care Direct Care
Workforce (PHI & Direct Care Workers Association of
North Carolina, 2008) and two papers which assessed
the activities of the CMS DSW Demonstration
grantees in the areas of marketing, recruitment and
selection and in providing health coverage.
Improve DSW wages
and access to benefits
States, providers and other disability stakeholders
are working to find ways of improving the
competitiveness of direct service jobs in the labor
market. Several policy tools have been used at the
state level. These include (Seavey & Salter, 2006;
PHI, 2008): 1) Targeted funding for wage add-ons
such as wage pass-throughs (e.g., a 60 cents per
hour increase or a 2% COLA); 2) Reimbursement
rate reform that changes the methods for rebasing,
or updating rates for the services and supports
provided by DSWs, or that provides for enhanced
rates for providers meeting higher standards relating
to their workforces; 3) Changes to procurement and
contracting standards in order to establish minimum
benchmark standards for providers to participate in
public programs, such as wage floors or requirements
that a minimum part of the service rate be allocated
to cover direct service labor costs; and 4) Creation
of public authorities to organize consumer-directed
Medicaid-funded services provided by independent
providers, allowing for collective bargaining on behalf
of DSWs in order to improve the quality of their jobs.
There are also approaches that lift the wages of
a broader gr
oup of low-wage workers, including
DSWs. For example, indexing the state minimum
wage to inflation can help low-wage workers receive
wage increases tied to changes in the cost of living.
Furthermore, a few states and several localities have
passed living wage laws that ensure a base minimum
wage that is substantially higher than the minimum
wage set by the state or federal government. These
efforts are not limited to long-term care but instead
extend to a larger set of occupations and industries
within these states.
Several states have created policies to encourage
the provision of health car
e coverage to DSWs as
a means of improving the quality of their jobs and
stabilizing this workforce. A recent report of PHI’s
Health Care for Health Care Workers initiative
documented five successful strategies used to
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A synthesis of direct service workforce demographics and challenges across intellectual/
developmental disabilities, aging, physical disabilities, and behavioral health
expand coverage for direct care workers. These
strategies are —
Make employer-based insurance more affordable •
through the use of purchasing pools to bring
down the cost of insurance or by using public
funds to subsidize employer or employee share
of pr
emiums.
Expand public insurance coverage by expanding •
eligibility for Medicaid or other public health
programs.
Establish coverage thr
ough collective bargaining •
allowing workers to negotiate for employer-
sponsor
ed coverage.
Build insurance costs into Medicaid •
r
eimbursement providing rate enhancements to
cover the cost of health coverage; and
Assist workers with health care expenses •
through the use of limited benefits products
like pr
escription discount car
ds, mini-med
plans, health savings accounts and health
reimbursement accounts.
The Centers for Medicare and Medicaid Services
(CMS) conducted demonstrations in this area that
modeled a number of these strategies, particularly
subsidizing employer based coverage and assisting
workers with health car
e expenses. The CMS study
and other research have documented the strong
positive link between health coverage and retention.
In addition, the CMS study offered some practical
guidance to others interested in pursuing health
coverage programs. First, that while subsidizing the
cost of insurance premiums can reduce the cost,
care must be taken to ensure they are affordable to
employers and workers. Second, that limited benefits
products and help with health care expenses can be
useful when a comprehensive plan is not available,
but they offer limited benefits and, for older
workers especially, there simply may not be enough
coverage. And finally, when states pursue any of
these strategies, it can be helpful to provide targeted
outreach to DSWs so that they understand their
health coverage options and receive assistance with
enrollment as needed.
Reform training and credentialing systems
Many states and providers are working to improve
their existing training and credentialing programs
for different groups of DSW workers, including
creating opportunities for advancement through
state-sanctioned career pathway and advancement
programs. These efforts are motivated by the goal
of providing DSWs with the knowledge and skills to
excel in their roles, by a desire to improve retention,
and by changes in service delivery systems, in
particular the dramatic expansion in the demand for
Home- and community-based services and supports
that many states are experiencing.
Several strategies can be distinguished. One
approach is to identify cor
e competencies for
DSWs on which training should be based in order
to support the development of consistent training
programs. In some states, these efforts have lead
to the development and implementation of a
standardized curriculum to train DSWs across the
state and/or to new streamlined credentialing and
certification programs for these groups of workers.
Many states and NADSP use Community Support
Skill Standards as the foundation of their training and
credentialing programs. These skill standards should
be updated.
Another approach has been to adopt U.S. DOL
apprenticeship pr
ograms for various types of DSWs.
To date, four such apprenticeship programs have
been developed: Direct Support Specialist, Certified
Nurse Assistant, Home Health Aide, and Health
Support Specialist. Apprenticeship programs combine
work place learning and related instruction and
require DSWs to complete a specified number of
hours of training and on the job skill implementation.
Upon the completion of training, apprenticeship
standards require that DSWs receive a wage increase.
Within behavioral health, some states are
developing peer support training and certificate
programs that pr
ovide intensive training, testing,
certification, continuing education and ongoing
technical support to consumers who wish to support
other persons in recovery. Certified Peer Specialists
are trained in a specific skill set to role model recovery
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A synthesis of direct service workforce demographics and challenges across intellectual/
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and teach self-directed recovery tools and serve in a
paid direct service role with other persons in recovery.
Reform long-term care payment
and procurement systems
Several states are working to develop systems to
reward provider investments to promote job quality,
encourage delivery of quality services, and include
workforce standards in quality assurance efforts.
One strategy in this area is to modify contracting
or procurement standards to establish minimum
benchmark standards for providers to participate in
particular programs. For example, standards related
to basic staff compensation (wages and benefits),
training, supervision, new worker orientation, and
career development. This approach requires the
employer to achieve benchmarks regarding the DSW
workforce as a component of their contract.
Another strategy is to provide incentive awards
or enhanced rates to providers who meet higher
standar
ds relating, for example, to improved turnover
or retention rates or enhanced training practices.
This provides an incentive for providers to adopt
new practices and often results in a better work
environment, increased wages or improved benefits
for DSWs.
Engage the public workforce and
education systems to support recruitment
and training of DSWs
Workforce Investment Boards across the country
are beginning to address the problem of health
care worker shortages but many still pass over
direct service employment in long-term care in their
assessments of high-priority occupations for receiving
workforce investment dollars. At the same time,
there are notable examples of efforts underway to
create strong partnerships between the workforce
development system, employers of DSWs, and
educational institutions such as community colleges
(Seavey, 2006). These are often designed to enhance
recruitment and job quality by improving training,
engaging in job redesign, and creating career
pathway infrastructures.
Collaboration with departments of labor can
bring together health and human service providers
who need to find, hir
e and train DSWs, using one-
stop networks to create pools of available workers
who have met pre-employment requirements. Finally,
another approach is to engage with the workforce
development system to cultivate an economic
development approach to developing multi-employer
industry partnerships focused on developing jobs
within the health care and health assistance sector,
including direct service jobs within long-term care.
At the same time, engaging with state departments
of education is critical to ensure that post secondary
and adult education programs targeting DSWs can be
developed and implemented.
Design worker registries and
other supportive resources
Some states have created new approaches to
support both consumers and workers in home-
and community-based services. This support is
especially important for workers and consumers
under consumer-directed programs. These supportive
activities can include developing comprehensive
worker registries that help workers find people who
need support and help consumers find people to
provide support. Developing worker professional
associations to enhance opportunities for networking,
professional development activities, policy advocacy
and empowerment is another strategy used in some
states. These associations often affiliate with NADSP
or the Direct Care Alliance.
28
A synthesis of direct service workforce demographics and challenges across intellectual/
developmental disabilities, aging, physical disabilities, and behavioral health
Develop statewide stakeholder coalitions
to develop and implement state level
workforce development plans
In several states, efforts have been made to bring
together advocates, individuals who receive
services, policy makers, workforce development
staff, educators, employers and other interested
stakeholders to identify the DSW challenges in those
states and then to develop and implement statewide
plans to address these challenges. This committed
focus often involves identifying strategies for funding
and shared resources.
Some states have developed strategies to provide
training and technical assistance to organizations
that employ DSWs on effective r
ecruitment,
retention, and training programs. These programs
have created train-the-trainer approaches to teach
individuals within the state how to deliver training
to providers on effective recruitment and retention
strategies such as: realistic job previewing, targeted
marketing, empowerment of workers, competency
based training, peer mentoring and other strategies.
Other states have developed systemic training for
supervisors and other workers on leadership and
effective supervision practices and have implemented
statewide train-the-trainer programs to support these
efforts.
29
A synthesis of direct service workforce demographics and challenges across intellectual/
developmental disabilities, aging, physical disabilities, and behavioral health
Areas for planning and action
Direct service workforce development challenges
warrant immediate and focused action on the part of
many stakeholders. The partners of the Direct Service
Workforce Resource Center present here several ideas
for actions steps that could be taken in partnership
across the various workforce sectors to address these
challenges. These ideas are based on published
research and the experiences of the Resource Center
partners in providing technical support to states and
organizations.
Areas of focus
Creating new partnerships and strengthening
existing partnerships
Many action steps can be taken to improve
collaboration across sectors in planning and taking
action to address direct service workforce challenges.
Creating new partnerships and strengthening
existing partnerships is a first step, followed by a
focus on other specific areas of action through these
partnerships.
Develop cross-sector partnerships to create •
a unified voice and mutual understanding
about the direct service workforce, its
challenges and strategies to resolve these
challenges.
Convene advisory and other
collaborative groups (at the federal, state
or local levels) that bring together multiple
departments within government and other
interested organizations across intellectual
and developmental disabilities, aging, physical
disabilities, and behavioral health services. These
groups would be charged with: 1) gathering
and using data and information to inform policy
makers, advocates and service recipients about
the status of the direct service workforce across
these three service sectors; and 2) making
recommendations about strategies to address
the direct service workforce challenges. In order
to encourage collaboration across government
agencies and in partnership with stakeholders,
membership on these groups should include
decision-making representatives from many
federal, state or local departments (based on the
level targeted) as well as representatives of key
stakeholder groups. Partnerships should include
but certainly not be limited to the following
groups —
State, federal or local government agencies
»
(e.g., Departments of Health and/or Human
Services, U.S. DOL and Department of
Education)
DSWs »
Community providers/employers
»
Family advocacy organizations
»
Self-advocates/service recipients
»
State and national policy organizations
»
University and private Research and Training
»
Centers with DSW workforce expertise
National protection and advocacy
»
organizations
Strengthen partnerships between health •
and human service agencies and the public
workforce system (e.g. Workforce Investment
Act programs and One-Stop Career Centers)
at national, state and local levels.
For many
states, the direct service industry will be a leading
growth industry over the next 20 years, given the
aging of the population and increased longevity
among younger people with disabilities. In some
regions, LTC employers are already among the
largest employers of low-wage workers, and
investing in these jobs can help community
economic development. Despite their workforce
and community economic development
potential, DSW workforce initiatives undertaken
by health and human services agencies and
organizations are rarely coordinated with the
workforce development system. Workforce
development systems should play critical roles in
responding to the increasing demand for DSWs.
30
A synthesis of direct service workforce demographics and challenges across intellectual/
developmental disabilities, aging, physical disabilities, and behavioral health
Private employers and industry associations must
be engaged in partnerships with the workforce
system agencies to identify strategies to
accurately assess the demand for DSW workers,
opportunities for improving recruitment and
retention practices, and the need for augmented
and enhanced training that better meets the real
needs of employers.
Education and training
Coordinated approaches to education and training
at the national, state, and local levels to improving
training for DSWs are critical to preparing greater
numbers of workers for direct service work as well as
ensuring the quality of supports and services provided
to consumers. Education and training encompasses
a wide gamut of activities including: identifying
competencies by conducting job analyses, developing
curricula, creating training systems infrastructure,
delivering training to various targeted learners, and
creating credentialing and certification programs.
Identify DSW core competencies and •
specialization competencies across sectors.
These competencies should draw on existing
job analyses and input from key stakeholders
to outline common knowledge, skills and
attitudes across employment sectors (intellectual
and developmental disabilities, aging, physical
disabilities, and behavioral health). The
competencies should be based on forward
thinking and current best practice so that they
identify the knowledge, skills and attitudes
required of exemplar DSWs today as well as
future workers. Competencies should serve as
the foundation for policy and practice regarding
education and training for DSWs at the national,
state and local levels.
Increase access to training, lifelong learning •
and career paths for DSWs across sectors.
Identify and implement strategies that increase
access to affordable training, education and
lifelong learning for DSWs. These training
and educational opportunities should lead to
career paths and articulated credentials that
connect with recognized skills and related
incentives. Training should use evidence-based
practices and be integrated into K-12 and post-
secondary educational programs as well as
other career and workforce training options,
such as apprenticeship and employer-based
training partnerships. Trainees enrolled in
existing educational programs should complete
regular self-assessments in order to evaluate
the relevance and effectiveness of their current
training.
Recruitment and retention
Joint efforts and collaboration to support employers,
families and individuals to find and keep good
workers constitutes an essential area of collaboration.
Across the sectors, poor recruitment and retention
leads to high rates of worker turnover, which in turn
results in poorer quality of service for consumers and
increased work stress for DSWs. Across all sectors,
considerable progress has been made in identifying
human resource practices that are consistent with
and support effective recruitment and retention.
Provide training and technical assistance to •
states and employers on effective evidence-
based recruitment, retention and training
interventions.
This training and technical
assistance should be disseminated throughout
the U.S. and target employers within the
sectors of intellectual/developmental disabilities,
behavioral health, physical disabilities and
aging. Training should address marketing and
recruitment, selection, orientation/socialization,
mentoring, supervisor training, organizational
cultural change, competency-based training,
and motivation and recognition. Strategies
should be highlighted that provide incentives
to organizations that successfully reduce their
turnover and vacancy rates, and improve
retention using the recommended strategies.
31
A synthesis of direct service workforce demographics and challenges across intellectual/
developmental disabilities, aging, physical disabilities, and behavioral health
Support the dissemination of effective •
supervisory practices for DSWs. The presence
of good basic supervision has been shown to
be a vital factor effecting the intent of DSWs to
stay in their jobs. In order to ensure that DSWs
in each sector have competent and well-trained
supervisors.
Effective training programs for
the frontline supervisors who guide and direct
the work of DSWs need to be developed and
disseminated. Training should build from existing
identified supervisor competencies within and
across each sector. These programs could be
accompanied by recommended supervision
standards that specify how often and in what
format supervision should be provided across
settings.
Keep training and worker support central to •
all consumer-directed service programs.
Under
consumer-directed programs, self-direction
takes several forms. For consumer-directed
programs in the aging, physical disability and
intellectual and developmental disability sector,
individuals and families typically hire and direct
their own DSWs. The individual served (or their
family as appropriate) becomes the employer
with family members, peer support workers,
friends, and neighbors often delivering the
services. In behavioral health models, persons in
recovery and family members provide self care
and peer support through voluntary and paid
roles. While consumer-directed programs rely
on non-traditional workers, training, supervision
and support remain critical for those providing
services. Individuals and families should have
access to training on how to find, choose and
keep their DSWs, as well as deliver effective
worker support. It is also important that the
DSWs who provide service under consumer-
directed programs are given opportunities to find
potential employers and to access training and
other supports, if desired.
Wages, benefits, and rate structures
Across the sectors, wages, benefits and
reimbursement rate structures have been identified
as issues that must be addressed to overcome direct
service workforce challenges. There is consensus
agreement across the sectors that these issues are
a priority. A unified voice and strong collaboration
could be effective in pursuing the following action
steps.
1. Increase the wages of DSWs across sectors.
Implement strategies to increase DSW wages
across sectors and settings, ensuring that this
workforce earns family sustaining wages in every
community throughout the U.S. Wage scales
should be developed that are commensurate
with competence, experience and levels of
responsibility.
2. Provide access to affordable health insurance
benefits to all DSWs across sectors.
Implement
effective strategies to ensure that all DSWs have
access to affordable health and dental insurance.
3. Redesign the long-term care payment and
procurement policies to reward investment
in the direct service workforce.
Identify and
implement rate and other payment strategies
that provide incentives for employers and
provider organizations to invest in the workforce,
improve retention, increase the competence of
their workers, and encourage the delivery of high
quality services and support. Include workforce
standards (i.e., retention of DSWs, vacancy rates
and DSW credentialing/certification) in quality
monitoring activities with states and providers.
Develop federal guidance to states concerning
both the monitoring of wages and benefits
paid to DSWs and the rate-setting principles
and standards that support an adequate and
stable dir
ect service workforce. Use federal
review processes and quality assurance systems
to provide guidance and technical assistance to
states concerning workforce monitoring and
effective payment methodologies for Medicaid
long-term care services and supports.
32
A synthesis of direct service workforce demographics and challenges across intellectual/
developmental disabilities, aging, physical disabilities, and behavioral health
Status and awareness
Enhancing the status and image of the direct
service workforce can improve recruitment efforts
and influence policymakers’ understanding of the
workforce development challenges facing this
workforce.
Create a national marketing and public •
awareness campaign for DSWs.
In
collaboration with the members of a cross-sector
stakeholder work group, create a well-designed
and comprehensive national, state and local
marketing and public relations campaigns to
inform citizens about the contributions that
DSWs make to our communities and to people’s
lives. Develop marketing materials and resources
for providers to use in recruiting DSWs through
workforce centers, K-12 education and other
community-based educational sites where
people seek career guidance.
Provide opportunities to listen and empower •
DSWs.
Create opportunities to include DSWs in
public discussions and public policy processes
regarding workforce as well as the programs
serving the individuals whom DSWs support.
Provide financial support to workers to facilitate
their participation. Provide support for national,
statewide and local professional associations for
DSWs.
Support national, state and local direct •
service recognition activities.
In 2008, the
U.S. Senate designated the week of September
8, 2008 to be Direct Support Professional
Recognition Week. States and local governments
have made similar designations.
Data collection, research, and evaluation
Collaborative efforts are key to encouraging the
collection of better state and national DSW workforce
data, evaluating DSW workforce development
practices and policies, and coordinating new research
and evaluation efforts and initiatives.
Establish a cross-sector state and national •
research and evaluation agenda on direct
service workforce issues.
Identify key
components of a research agenda that furthers
understanding of the entire direct service
workforce and can be used to shape state and
federal public policy. This research agenda should
include rigorous evaluation methods to identify
effective organizational and policy interventions.
Support the development of national job •
quality/ workforce indicators for direct
service occupations, relating, for example,
to turnover rate, staffing levels, and
compensation.
These indicators could be useful
to policy makers and industry leaders in creating
incentives for adequate and safe staffing, and
greater workforce stability.
Establish cross-sector data collection systems •
at the federal and state levels.
Data collection
should encompass key indicators of workforce
stability, size, and compensation for publicly
financed health and human service programs.
Regular workforce monitoring should be
instituted and made publicly available. Finally,
occupational and industry codes and definitions
that are used by state and federal labor
departments in establishment surveys should
be updated in order to provide a more accurate
count of DSW employment and wages.
33
A synthesis of direct service workforce demographics and challenges across intellectual/
developmental disabilities, aging, physical disabilities, and behavioral health
Conclusion
Across the aging, physical disability, intellectual
and developmental disability, and behavioral
health sectors there are ever-present, pervasive
direct service workforce challenges. While there
are important differences across the sectors, many
challenges each sector are experienced in similar
ways. Most importantly, each sector has accumulated
considerable knowledge concerning effective
practices and policies for addressing these challenges.
As a result, important opportunities exist for
collaboration, networking and sharing of information
and resources.
The key strategic areas for collaboration identified
by the partners of the DSW Resource Center ar
e
compensation, training and education, recruitment
and retention, reimbursement rate structures and
procurement systems, status and awareness, and
data collection, research and evaluation. Coordinated
initiatives across these areas are needed to develop
the capacity of service delivery systems to meet
the needs of long-term care consumers for quality
services and supports by ensuring an adequate and
well-prepared direct service workforce.
34
A synthesis of direct service workforce demographics and challenges across intellectual/
developmental disabilities, aging, physical disabilities, and behavioral health
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Appendix A
Community Support Skill Standards
In a focused initiative to create standards in the broad
community human service field, the Community
Support Skill Standards (CSSS) project conducted
an in-depth study of DSWs who have the most
direct responsibility and contact with human service
participants and the greatest impact on the service
outcomes. This project was funded by the U.S.
DOL to identify skill standards across high growth
occupations. The CSSS project used a structured
DACUM (Development of a Curriculum) analysis
process to study and validate DSW roles and to write
and validate a set of skill standards. The CSSS are not
designed to be a set of minimal skills for entry level
workers but rather a set of “master level” skills for a
more experienced worker who is viewed by peers and
others as competent. The CSSS are designed around
12 broad areas of skills needed for effective direct
support work. The list is prioritized —
1. Participant empowerment — The competent
community support human service practitioner
enhances the ability of the participant to lead
a self-determining life by providing the support
and information necessary to build self-esteem,
and assertiveness; and to make decisions.
2. Communication — The community support
human service practitioner should be
knowledgeable about the range of effective
communication strategies and skills necessary
to establish a collaborative relationship with the
participant.
3. Assessment — The community support human
service practitioner should be knowledgeable
about formal and informal assessment practices
in order to respond to the needs, desires and
interests of the participants.
4. Community and service networking — The
community support human service practitioner
should be knowledgeable about the formal
and informal supports available in his or her
community and skilled in assisting the participant
to identify and gain access to such supports.
5. Facilitation of services — The community support
human service practitioner is knowledgeable
about a range of participatory planning
techniques and is skilled in implementing plans
in a collaborative and expeditious manner.
6. Community living skills and supports — The
community support human service practitioner
has the ability to match specific supports and
interventions to the unique needs of individual
participants and recognizes the importance of
friends, family and community relationships.
7. Education, training and self-development — The
community support human service practitioner
should be able to identify areas for self
-improvement, pursue necessary educational/
training resources, and share knowledge with
others.
8. Advocacy — The community support human
service practitioner should be knowledgeable
about the diverse challenges facing participants
(e.g., human rights, legal, administrative and
financial) and should be able to identify and use
effective advocacy strategies to overcome such
challenges.
9. Vocational, educational and career support -—
The community based support worker should be
knowledgeable about the career and education
related concerns of the participant and should
be able to mobilize the resources and support
necessary to assist the participant to reach his
or her goals.
10. Crisis intervention — The community
support human service practitioner should
be knowledgeable about crisis prevention,
intervention and resolution techniques and
should match such techniques to particular
circumstances and individuals.
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A synthesis of direct service workforce demographics and challenges across intellectual/
developmental disabilities, aging, physical disabilities, and behavioral health
11. Organization participation — The community
based support worker is familiar with the mission
and practices of the support organization and
participates in the life of the organization.
12. Documentation — The community based
support worker is aware of the requirements for
documentation in his or her organization and is
able to manage these requirements efficiently.
The Community Residential Core Competencies
(CRCC) were validated in a study that r
eplicated the
DACUM process specifically with DSWs employed
in a variety of residential living environments and
who provide supports to people with intellectual and
developmental disabilities. This validation process
yielded results that indicated a strong overlap
between the CSSS and the knowledge, skills, and
attitudes required of DSWs in community residential
services. The identified CRCC provides more specific
areas of competence than the CSSS. However, the
CRCC do fit into the broader CSSS competency areas.
The CRCC competencies were further validated as
relevant to residential DSWs in a study of DSWs,
supervisors and managers from four states (Larson,
Doljanac, Nord, Salmi, Hewitt, & O’Nell, 2007). They
are listed in order of priority as identified in the study
(Hewitt, 1998) —
1. Household management — Assists the individual
with household management (e.g., meal
preparation, laundry, cleaning and decorating)
and with transportation needs to maximize his
or her skills, abilities and independence.
2. Facilitation of service — Staff has knowledge
sufficient to fulfill his or her role related
to individual service plan development,
implementation and review.
3. Health and wellness — Promotes the health
and wellness of all consumers.
4. Organizational participation — Staff is familiar
with the organizational mission.
5. Documentation — Staff is aware of the
requirement for documentation in his or her
organization and is able to manage these
requirements efficiently.
6. Consumer empowerment — Enhance the ability
of the individual to lead a self-determining life by
providing the support and information necessary
to build self-esteem, and assertiveness and to
make decisions.
7. Assessment — Staff is knowledgeable about
formal and informal assessment practices in
order to respond to the needs, desires and
interest of the individuals.
8. Advocacy — Staff should be knowledgeable
about the diverse challenges facing individuals
(i.e., human rights).
9. Community and service networking — Staff is
knowledgeable about the formal and informal
supports available in his or her community and is
skilled in assisting the individual to identify and
gain access to such supports.
10. Building and maintaining friendships and
Relationships — Support the participant in
the development of friendships and other
relationships.
11. Communication — Staff is knowledgeable about
the range of effective communication strategies
and skills necessary to establish a collaborative
relationship with the individual.
12. Crisis intervention — Staff is knowledgeable
about crisis prevention, intervention, and
resolution techniques and should match such
techniques to particular circumstances and
individuals.
13.
Professionalism —Staff pursues knowledge and
information necessary to perform job duties.
14. Vocational, education, and career support —
Staff is knowledgeable about the career and
education related concerns of individuals.
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A synthesis of direct service workforce demographics and challenges across intellectual/
developmental disabilities, aging, physical disabilities, and behavioral health
PHI competencies and skill standards
for Direct Care Workers
In aging and physical disability services, a set of
competencies and skill standards has been developed
by the PHI for direct care workers (DCWs) who work
in settings that provide supports for persons with
long term care needs. Competency areas identified in
this skill set include —
1. Role of the direct care worker — The DCW will
understand their role within the service team and
how their role is focused on the needs and issues
of the consumer. The DCW will demonstrate
professionalism and responsibility to their job
and profession.
2. Consumer rights, ethics and confidentiality
— The DCW will respect consumers and their
personal preferences at all times. They will
empower consumers and ensure they are treated
with dignity and respect.
3. Communication, problem-solving and
relationship skills — The DCW will be able to
communicate professionally and effectively with
consumers and others. The DCW will resolve
conflicts courteously while ensuring consumer’s
preferences are respected.
4. Personal care skills — The DCW will provide
quality personal care services to residents at all
times and provide them in a way that is most
comfortable to the consumer.
5. Health related tasks — The DCW will provide
quality health related supports to consumers to
ensure their health and well being at all times.
6. In-home and nutritional support — The DCW
will support consumers in living independent and
meaningful lives. The DSW will provide support
to consumers in their homes and assist them
in making their homes safe while supporting
healthy nutrition.
7. Infection control — The DCW will follow all
procedures related to infection control at all
times to ensure the health and well being of
consumers and themselves.
8. Safety and emergencies — The DCW will use
proper techniques when lifting and transferring
consumers. The DSW will check equipment
regularly and know how to respond to
emergency situations.
9. Apply knowledge to the needs of specific
consumers — The DCW will respect and treat
each consumer as an individual. The DCW will
have knowledge of how aging and illness affect
each consumer differently.
1
0. Self care — The DCW will have knowledge
and access to organizational and community
resources to assist them in reducing stress and
preventing burnout.
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A synthesis of direct service workforce demographics and challenges across intellectual/
developmental disabilities, aging, physical disabilities, and behavioral health
Certified psychiatric rehabilitation
practitioner competencies
The competencies for Certified Psychiatric
Rehabilitation Practitioners (CPRP) were created
to guide training and certification of practitioners
in the field. Prior to certification, practitioners
were part of a voluntary registry. These systems
did not provide for accurate, standardized, and
cohesive practice standards. The United States
Psychiatric Rehabilitation Association (USPRA)
was responsible for commissioning a consulting
organization to develop, administer, and score
the new certification examination for Psychiatric
Rehabilitation Practitioners. A set of competencies,
organized around domains, was used to create a
standardized test in the field. Each learner is tested
in each of the 7 Domains. Due to the depth and
complexity of CPRP domains with task, knowledge,
and skill statements, the full competency set cannot
be listed here. For further information and detail, the
reader is encouraged to review and/or download the
competencies at the U.S. Psychiatric Rehabilitation
Association Web site at: http://www.uspra.org/i4a/
pages/index.cfm?pageid=3924
The following is a list and description of CPRP
competency statements for each of the seven
domains —
1. Interpersonal competencies — CPRPs are
expected to engage in healthy interpersonal
communication with clients, families, and other
professionals. CPRP’s should seek to maximize
interaction between clients and families.
2. Professional role competencies — CPRPs will
review emerging literature and seek to increase
their skills and knowledge base through
continuing education and training.
3. Community resources — CPRPs are expected to
create linkages with other community resources
and assist clients in creating natural supports.
CPRPs will match client’s needs with various
community resources and assist in integrating
the resource with other treatment supports.
4. Assessment, planning, and outcomes — CPRPs
are expected to engage in mutual treatment
planning, goal setting, holistic assessment, and
crisis management. CPRPs will evaluate client
outcomes and seek to ensure client satisfaction
and success.
5. Systems competencies — CPRPs will fight
discrimination and protect client’s civil rights and
liberties. CPRP’s will advocate for clients at the
community, local, and state levels and empower
clients to become self advocates.
6. Interventions — CPRPs will seek to actively
engage clients. CPRP’s will support and teach
skills, develop leaders, promote effectiveness and
achievement, and instill hope in clients. CPRP will
engage in outreach services.
7. Diversity — CPRPs will provide culturally sensitive
and appropriate services to all clients. Diversity
incorporates the inclusion of all populations
and expects CPRPs to assist in identifying and
removing institutional barriers. (USPRA, 2008)
Addiction counseling competencies
Since 1998, the Substance Abuse and Mental Health
Services Administration (SAMHSA) and the Center for
Substance Abuse Treatment (CSAT) have been actively
developing and publishing addiction counseling
competencies. This set of competencies was initially
developed by a national curriculum committee as
a technical assistance publication (TAP 21). The
Addiction Counseling Competencies: The Knowledge,
Skills, and Attitudes of Professional Practice has been
widely distributed and provides concrete benchmarks
as well as a tool for which training and curriculum
can be developed for professionals in this field. This
essential tool continues to be monitored and updated
by its national curriculum committee and was last
updated in 2005.
The core set of Addiction Counseling
Competencies has 12 competency areas and each
competency ar
ea has a number of competency
statements, knowledge areas, skill sets, and attitude
statements. Due to the depth and complexity of the
49
A synthesis of direct service workforce demographics and challenges across intellectual/
developmental disabilities, aging, physical disabilities, and behavioral health
core set of Addiction Counseling Competencies,
the entire set cannot be listed here. For further
information and detail, the reader is encouraged
to review and/or download the entire set from the
U.S. Department of Human Services and SAMHSA’s
Clearinghouse for Alcohol and Drug Addiction
Web site at: http://ncadistore.samhsa.gov/catalog/
productDetails.aspx?ProductID=13283
The following list identifies the 12 compe-
tency areas for the core set of Addiction Coun-
seling Competencies (foundations and practice
dimensions) —
Foundations
1. Understanding addiction — Counselors will
have an understanding of current models of
theory and treatment. Counselors will seek to
understand how social, cultural, and economic
factors influence addiction.
2. Treatment knowledge — Counselors will
understand models of addiction, treatment,
the importance of family and communities in
recovery, and the interdisciplinary approach
to treatment. Counselors will use research,
literature, and outcome data to provide the best
clinical treatments.
3. Application to practice — Counselors will use
diagnostic criteria, various treatment modalities,
and placement criteria to provide the most
tailored treatment approach. Counselors will use
helping strategies, pharmacological resources,
and other insurance or entitlement programs to
provide customized treatment.
4. Professional readiness — Counselors will
provide culturally sensitive treatment and be
sensitive to issues of diversity. They will adhere
to responsibilities of the profession and seek
to have a level of healthy self awareness.
Counselors will actively participate in treatment
plans and crisis management.
Practice dimensions
1. Treatment planning — Counselors will consider
all treatment options for clients, assess client’s
readiness for treatment, and inform clients
of their rights. Counselors are responsible for
coordinating treatment activities and accessing
appropriate resources.
2. Referral — Counselors will maintain a network
of community resources and be aware of various
treatment options and services in their area.
Counselors will exchange information with
referral sources when appropriate and know
how and when to make a referral for service.
3. Client, family, and community education —
Counselors will provide culturally sensitive and
relevant information about addiction to clients,
their family, and the community. Counselors
will provide education and explain the addiction
process and teach others about treatment,
recovery, and prevention.
4.
Documentation — Counselors will document
in detail all aspects of a client’s treatment
while rigorously ensuring client confidentiality.
Counselors will handle client records with
extreme care to approved third parties.
5. Service coordination — Counselors will
encourage an interdisciplinary team approach
to treatment. The team will be informed and
educated about treatment, addiction, and
recovery. Team members will be encouraged
to support and engage the client in order to
maximize the client’s resource base and success.
6. Professional and ethical responsibilities —
Counselors will follow a professional code
of conduct, as well as all state and federal
regulations. The primary concern for counselors
is ensuring the safety and well being of clients.
Counselors will pursue continuing education and
training and review emerging literature.
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A synthesis of direct service workforce demographics and challenges across intellectual/
developmental disabilities, aging, physical disabilities, and behavioral health
7. Counseling — Counselors will create a warm,
genuine, and respectful relationships with
clients while setting healthy boundaries and
encouraging empowerment. Counselors will
provide safe environment with supportive
therapeutic techniques.
8. Clinical evaluation — Counselors will build
rapport with clients. They will gather data,
screen, assess, and apply diagnostic criteria
when appropriate. Counselors will assist clients
in understanding their addiction and make
treatment recommendations.
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