New report on long-term services and supports in Baltimore

A framework for improving job quality and creating a highly trained direct care and services workforce

March 17, 2023

The Maryland Regional Direct Services Collaborative has released a new report that examines the factors driving the crisis in Baltimore City’s direct care and services workforce and makes recommendations to improve job quality for care professionals.

Staffing challenges have vexed nursing homes, assisted living facilities, and home- and community-based care settings since before the pandemic, and they are not likely to abate until systemic solutions are identified and implemented. As the report illustrates, the direct care and services workers (DSWs) who work in long-term services and supports (LTSS) settings in Baltimore City—and the thousands of people who depend on their care—need solutions sooner rather than later.

Through research and in-depth stakeholder interviews, the following themes emerged:

• Inadequate compensation is the single biggest factor driving the workforce crisis. Nearly all stakeholders, including DSWs, recognize that wages are not high enough to compete with restaurant and retail wages, and many are aware that they do not meet the criteria for a living wage. Further, in some LTSS settings, such as home care, lack of benefits may be tied to the practice of misclassifying workers as independent contractors, which denies them employment benefits such as earned sick or vacation leave, extra pay for overtime hours, or even protection by workers’ compensation programs.
• Medicaid reimbursement rates are not high enough to allow many LTSS providers to increase wages to necessary levels. Because so much of the care provided in Baltimore and throughout Maryland is funded by Medicaid, the program’s reimbursement rates drive workforce dynamics. Providers and advocates consistently assert that Maryland’s reimbursement rates have not increased at a level necessary for LTSS owners and operators to offer competitive compensation to DSWs.
• DSWs in nursing homes and assisted living facilities see low staffing ratios as diminishing job quality. Nearly all DSWs in these settings report dissatisfaction with staffing ratios. Many say that these low ratios make it very difficult to provide the level of care that they want, or are able, to provide. The increased workload that results from low staffing ratios adds to burnout and exhaustion, as well as the feeling that DSWs are being asked to do the jobs of two or three people.
• Respect and appreciation help but are insufficient on their own. DSWs point to symbols of appreciation from their employers as improving their job satisfaction, which may improve retention on the margin. However, respect and appreciation will not alone solve the systemic problems underlying the workforce crisis.
• Holistic training and support are appreciated, but also are insufficient on their own. Similarly, good quality training provided in conjunction with holistic supports and wraparound services can help provide DSWs with the tools they need to obtain certifications, feel supported in their workplaces, and remain in care jobs. However, training and support alone will not solve the problem.

Solutions to the LTSS workforce shortages are not easy ones. To that end, the Maryland Regional Direct Services Collaborative is committed to working with relevant stakeholders to develop and support solutions that help to improve job quality for direct care and services professionals and resolve the workforce crisis in Baltimore City and beyond.

RECOMMENDATIONS

Given the themes and findings, the report makes the following recommendations:

1. Push for state-level legislative and policy changes that both increase Medicaid funding for care and ensure that publicly funded DSW jobs offer living wages and benefits.
   Given that Medicaid funds so much of the care provided in Baltimore City, it is the single biggest lever for effective change. Maryland sets a wide range of key Medicaid rules through state laws, regulations, and policies within the Maryland Department of Health. Baltimore City’s Mayor and state legislative delegation should unite around a core message: Maryland should both increase funding for Medicaid-funded care and ensure that all Medicaid-funded DSW jobs offer living wages and benefits. Maine’s model of increasing Medicaid funding while also requiring that DSWs receive wages that are at least 25 percent greater than the state’s minimum wage offers a successful case study to draw from.
2. Leverage the Baltimore City Health Department’s Division of Aging and Care Services to collect more first-person data on the City’s DSW workforces. There is an unfortunate lack of comprehensive data about Baltimore City’s DSW workforces. This lack of data makes it harder to understand the forces driving the DSW workforce crisis and how to solve it. Every Maryland county has an Area Agency on Aging. Baltimore City’s is located within its health department and is called the Division of Aging and Care Services. It should do more to collect data on wages, benefits, turnover, and retention of DSWs in the City.
3. Consider dedicating funds to supplement wages for Medicaid-funded DSWs. Maryland does not yet ensure that DSWs who provide Medicaid-funded services are paid living wages. Baltimore City should consider a dedicated funding stream to make up the difference, helping to stabilize the DSW workforce until the state acts.
4. Connect DSWs to all available social services and supports. Though there are promising services offered by Baltimore City agencies and nonprofits, there is not yet a comprehensive effort to connect the City’s DSWs to all available social services and public benefits. Such an effort could leverage existing supports to make DSW jobs more appealing.
5. Invest in initiatives that offer DSWs access to obtainable and meaningful career pathway and advancement opportunities, such as career ladders (to licensed practical nurse, nurse, or administrator roles) and lattices (additional certifications for dementia care, infection control, end-of-life care, and more) that involve additional training matched with a raise in pay, an elevation in title, and/or new responsibilities or functions.
6. Explore the possibility of establishing a worker-owned cooperative. While not a panacea, worker cooperatives can help improve wages and retention. The Bronx’s Cooperative Home Care Associates offers an attractive model to learn from.

Read the full report here.

The report was written by Meg LaPorte, Executive Director, Maryland Regional Direct Services Collaborative and David Rodwin, Public Justice Center attorney and Collaborative Vice Chair. The report was funded by the Abell Foundation.