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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:

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.


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.