A Call for Systems Change to Address the Wage Disparity of Direct Support Professionals

Across the nation there is growing concern and discussion about a workers’ need for, and right to, earn a livable wage. In fact, in New York State – in a process that bypassed the need for Legislative approval – the Department of Labor Commissioner ordered that the minimum wage for certain fast-food workers be increased to $15 an hour based on the recommendation of a panel appointed by the Governor.

While the National Alliance for Direct Support Professionals (NADSP) applauds efforts to bolster salaries to ensure Americans earn livable wages, we also believe that a significant segment of the nation’s workforce, upon whom so many depend for daily support and well-being, should be included and not overlooked in these efforts – Direct Support Professionals. Addressing the economic needs of this segment of the workforce requires the concerted attention of national and State policy makers because its wages are largely dependent on public programs, i.e., Medicaid and Medicare.¹

About Direct Support Professionals

Direct Support Professionals (DSPs) are members of the long-term care workforce and are classified by the U.S. Department of Labor under a number of occupational titles including Personal Care Assistant/Home Care Aide, Home Health Aide and Nursing Assistant. In the agencies where they are employed, they may be known by a variety of specific titles such as Residence Counselor, House Parent, Life Skills Specialist, Personal Care Assistant, Aide, Mental Health Technician, etc.

DSPs work in various sectors of the human service system, supporting individuals with intellectual and developmental disabilities (I/DD), and people with behavioral health and substance abuse issues, physical disabilities, and problems associated with aging and/or medical conditions. Their role is to provide day-to-day assistance to individuals who need support in order to navigate the tasks of daily living with as much independence as possible. Their work is as diverse as the individuals they support because the nature of the support they provide is tailored to the assistance required by the individual. Some people may need hands-on assistance to dress, bathe, prepare meals, or do other daily tasks; while others may need assistance in navigating the communities where they live and in availing themselves of the services and opportunities there, and still others may need support in planning, decision making, and executing the plans they’ve made. DSPs support people with disabilities to have good lives.

The Crisis

As society’s demographics change (due to aging baby boomers, improved health care, longer life expectancy, etc.), the demand for DSPs is growing. The number of Americans estimated to need long term services and supports is expected to more than double, from 13 million in 2000 to 27 million in 2050². In the field of I/DD services specifically, it was estimated that the number of individuals requiring DSP supports would increase 38% between the years 2003 and 2020 necessitating a 37% increase in DSPs.³

According to the US Bureau of Labor Statistics, DSPs are among the top six fastest growing occupations. Compared to 2012, it is estimated that there will be a nearly 40% growth in DSP jobs, nearly three times the projected rate for fast food workers.⁴

While the need for support services is increasing, there are also changes in the types of supports requested. People with disabilities and those who are aging have demanded to be supported in the least restrictive environment, and the courts have agreed⁵. This has paved the way for public policy changes on the nature and location of supports and increased the complexity of the DSP role. Increasingly, DSPs are supporting individuals in individualized residential and other settings as opposed to institutions and sheltered environments. This requires more of the DSP than the ability to follow instructions issued by an immediate supervisor who years ago may have worked on the same ward or in a nearby office. It requires grounding in ethical standards and the ability to exercise independent judgment and professional skills.

While the demands for and of DSPs are growing, States are reporting significant problems in recruiting and retaining them. According to The 2007 National Survey of State Initiatives on the Direct-Care Workforce, “97% of responding States reported that DSP turnover and vacancies constituted a serious workforce issue.”⁶ A study released in 2010 indicated that the average DSP turnover rate in private-operated agencies in the I/DD field in 46 States was 38.2%.⁷

Commenting on this issue, the Institute of Medicine stated:

“Direct care workers have rewarding but difficult jobs, and they are typically very poorly paid and receive little or no training for their duties. As a result, turnover rates are high, and recruitment and retention of these workers is a persistent challenge. In the context of rapidly increasing demand for direct-care services, the need for these workers is beginning to reach a crisis stage.”⁸

Data provided by PHI support the Institute of Medicine’s opinion: the median annual earnings of direct care corkers is $17,000, 30% of whom are uninsured and 47% receive some sort of public assistance such as Medicaid or food stamps.⁹ Many have to work two or even three jobs to make ends meet and provide for families, or leave jobs they love in search of better wages and benefits.

The Need for Action

NADSP’s ideological founder, John F. Kennedy, Jr., wrote: “Quality is defined at the point of interaction between the staff member and the individual with a disability.” Assuring quality supports for individuals with disabilities now, and in the future, requires the availability of a stable, competent, and committed direct support professional workforce.

This requires that policy makers on the federal and state level address the financial underpinnings of the Medicaid and Medicare systems which provide for the wages and benefits of the majority of staff who directly support the needs of people with disabilities.

Toward that end, we recommend that these systems:

• Support a meaningful wage and health insurance benefits that are commensurate with the complex skills and ethical standards required by direct support professionals;
• Provide for cost-of-living adjustments to offset inflationary factors;
• Assure that direct support professionals receive paid training and objective evaluation in core competencies and ethical standards necessary for their job; and
• Provide opportunities to make direct support a life-long career by creating career ladders through advanced training and certification/credentialing. Each rung of a ladder, which would be tied to salary increases , should reflect proficiency in more complex work (e.g., interfacing and advocating with medical care professionals or benefit administrators, etc.) or specialty areas (working with individuals with serious medical or behavioral issues, etc.) associated with the provision of direct supports.

The time to act is now. Many of our parents, brothers, sisters and children depend on it. And some day, many of us will too.

• ¹Howes, C. (2014). Raising Wages for Home Care Workers: Paths and Impediments. A Paper Series Commemorating the 75th Anniversary of the Fair Labor Standards Act, 241.
• ²Department of Health and Human Services (2003). The Future Supply of Long-Term Care Workers in relation to The Aging Baby Boom Generation, Report to Congress.
• ³Department of Health and Human Services (2006). The Supply of Direct Support Professionals Serving Individuals with Intellectual Disabilities and Other Developmental Disabilities: Report to Congress.
• ⁴U.S. Department of Labor, Bureau of Labor Statistics Employment Projections 2012-2022. Accessed at www.bls.gov/emp/ep_table_103.htm.
• ⁵Washko, M. M., Campbell, M., Tilly, J. (2012). Accelerating the translation of research into practice in long term services and supports: A critical need for federal infrastructure at the nexus of aging and disability. Journal of Gerontological Social Work, 55 (2), 112-125.
• ⁶PHI and Direct Care Workers Association of North Carolina (2009). The 2007 National Survey of State Initiatives on the Direct-Care Workforce: Key Findings.
• ⁷ANCOR (2010). 2009 Direct Support Professionals Wage Study.
• ⁸IOM (2008). Retooling for an aging America: Building the health care workforce.
• ⁹PHI (2012). The direct-care worker at a glance (2010). Accessed at http://phinational.org/sites/phinational.org/files/wp-content/uploads/2012/05/DCW-ataglance-20120501.pdf