Strengthen the Workforce & Enhance Rural Sustainability

The Need


The direct care workforce is the backbone of the HCBS system. These frontline workers enable members to remain living safely in their homes and communities. Unfortunately, pre-COVID workforce shortages have been further exacerbated by the impacts of the pandemic as well as the increase in demand for HCBS services. Additionally, our direct care workforce has served on the frontline, risking their health and safety to ensure our members maintain theirs.

Recruitment and turnover among frontline staff are the most frequently reported provider challenges. Provider recovery payments and wage pass-throughs will provide short-term relief to ensure provider solvency and a wage increase to both reward and retain committed direct-care staff. This will be done in a reasonable ratio and in complement to longer-term, transformational strategies. Incentives to these workers to both thank them for their commitment throughout the pandemic and to recruit and retain them into the future, are also important rewards that will help strengthen and grow the workforce. In addition to direct payments to workers, enhancing the system to better train, support, and advance direct care workers, will ensure higher quality services are delivered resulting in better health outcomes for members. The capacity of the provider network, particularly in rural communities, is thin - driven by the limited workforce availability, difficult economic conditions, and long distances that must be traveled to serve community-based members. Investments in the workforce to expand recruitment and improve retention will bolster both provider capacity and members’ quality of care. A particular emphasis on rural provider sustainability will be made to ensure access to care across the state.

Initiative 1.01. - Increase Payments to Providers and Workers

At the heart of the ARPA is the call to support the recovery for those most impacted by the COVID-19 pandemic. Older adults and people with disabilities, their families, and those that support them have been devastatingly affected by this virus and the full extent of the impact has yet to be felt. As we emerge from the pandemic, stabilizing the direct care workforce is the most immediate priority. For that reason, as of January 1, 2022 the Department, in collaboration with the Polis-Primavera administration, implemented a $15/hour base wage for Colorado’s Medicaid, HCBS direct care workers and a rate increase for provider agencies.

A rate increase to accommodate a new $15 per hour base wage requirement for frontline staff providing direct hands-on care implemented on Jan. 1, 2022 through April 15, 2023. The services targeted for this increase include:

  • Adult Day
  • Alternative Care Facility
  • Consumer-Directed Attendant Support Services (CDASS)
  • Community Connector
  • Day Habilitation
  • Homemaker
  • In-Home Support Services (IHSS)
  • Mentorship
  • Personal Care
  • Prevocational Services
  • Residential Habilitation
  • Respite Care
  • Supported Community Connections
  • Supported Employment
  • Supportive Living Program

The Department understands that direct care workers’ wages vary considerably across geography, provider type, and internally, depending on experience and length of employment. For this reason, the expectation will be that all direct care workers currently employed receive at least $15 an hour. All new Home and Community-Based Services direct care workers hired after Jan. 1, 2022, must also have a wage of at least $15 per hour.

In addition to the rate increase for the new base wage, the Department has also increased provider rates for the services listed above except for Consumer-Directed Attendant Support Services (CDASS), and adding Non-Medical Transportation, by 2.11% retroactively to April 1, 2021, and going forward through July 31, 2022. 

To ensure stability across the long-term services and supports continuum, case management will be increased by 2.11% from April 1, 2022 through June 30, 2023, pending federal approval. Additional adjustments will be made for the Program for All Inclusive Care for the Elderly (PACE) providers due to common policy changes within HCBS as well as a rate increase next calendar year.

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Initiative 1.02. -  Direct Care Workforce Data Infrastructure

Under this project, the Department will expand the data infrastructure to better understand the current supply and demand for direct care workers and to track the impact of each investment strategy on recruitment, retention, and turnover. The Department will develop two surveys for the direct care workforce. The first survey will be a staff stability survey for providers of long-term services and supports (LTSS) waiver services and will include data collection on the number of direct care workers (DCWs) providing care, turnover rates of DCWs, percentage of DCWs that are full-time or part-time, DCW vacancy rates, and hourly wages for all DCWs. The second survey will be for direct care workers rather than the employers to determine their satisfaction with compensation, benefits, career advancement, training, and their overall satisfaction with their employment. This survey will evaluate why there is a workforce crisis among direct care workers and what the Department can do to address it. The surveys will be administered multiple times to supply comparative data. This project will fund the development of the surveys, data collection, and analysis. These surveys will assist in strengthening the data infrastructure in the short and long-term to better understand the workforce and evaluate the strategies outlined in this plan.  

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Initiative 1.03. -  Standardized Core Curriculum & Specialization

The Department will develop a standardized curriculum and training program for homemakers and personal care workers to establish quality standards, as well as increasing specialized qualifications tied to wage increases. The Department will develop a homemaker and personal care worker curriculum to include modules on specialized topics, such as Alzheimer’s disease and related dementias and mental and behavioral health care and make the training available for free in-person through a train-the-trainer model and online. Initial work has already been completed via the Training Advisory Committee per SB 19-238, “Improve Wages and Accountability Home Care Workers.” 

Training materials will be developed using a ‘universal worker’ structure, designed for use by individuals working in a variety of settings and with different populations. The modules will be adaptable depending on the employer, client, and worker’s needs, and training certificates will be transferable across employers. Funding will support training development, creation and launch of the online training platform, hosting statewide train-the-trainer sessions, and pilot testing and evaluating the new curriculum. Training materials will be available on the newly created Resource and Job Hub (initiative 1.04) for sustainability and ongoing management.

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Initiative 1.04. - Resource and Job Hub

The Department will create a resource, job search, and employer matching hub for direct care workers to ease their entry into the job. This funding will support the development of a website for the direct care workforce where interested individuals can go to receive information and resources about direct care positions, access free training, and view job boards to quickly be placed in positions. The newly developed personal care/homemaker training will be accessible through this site, and individuals who completed the training would be entered into a database for easy tracking of certification. The Department is partnering with our internal health information office and the State’s Office of Information Technology to ensure long-term sustainability of the site.

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Initiative 1.10. - Rural Sustainability and Investment 

Investing in rural communities to strengthen care access is critical in Colorado. This initiative will include implementation of three key strategies to ensure the sustainability of providers in rural communities, with the focused aim of strengthening and enhancing Colorado’s Medicaid and HCBS workforce. These initiatives are especially targeted at bolstering Colorado’s rural Medicaid and HCBS infrastructure, providers, and members. These strategies include: Identifying Care Gaps, Developing Geographic Modifiers, and Creating Shared Systems in Rural Communities. 

The first of these strategies is to expand the provider network in rural communities by identifying gaps and potential opportunities for expansion. A care desert, also known as medical deserts, exist mostly in rural places and inner cities and lead to inequalities in health care. The federal government now designates nearly 80 percent of rural America as ‘medically underserved.’ About 20% of the U.S. population live in rural areas, but only 10% of doctors and other health care professionals operate in those regions, and that ratio is worsening each year. 

The Department first needs more data and analysis on where there are care deserts and potential solutions in those areas. The Department will complete an environmental scan of Colorado’s current HCBS provider network via a GIS heatmap; create a tool for the Department to update and track progress on a statewide level; identify gaps by waiver, service, and provider type; find out which populations are the most impacted; and give recommendations for provider or service expansion and solutions in a final report.

One way to help prevent a care desert is to pay providers differently by region to account for differences in cost structure, which would encourage more people to work in direct care professions in areas that are currently underpaid. The Department will design rates by geographic region to account for the cost differential associated with different locations. Geographic modifiers are intended to improve the appropriateness of Medicaid rates to providers by accounting for the differences in prices for certain expenses, such as clinical and administrative staff salaries and benefits, rent, malpractice insurance, and other defined costs. The Department is dedicated to identifying ways for implementing these proposed geographic rates if found advantageous in the Sustainability Plan.

The workforce shortage is particularly concerning in rural areas. The Department will research ways to partner with hospitals and rural health clinics to identify opportunities to share resources and/or more efficiently and creatively offer services in rural areas. The goal of this initiative is to increase access to services by setting up partnerships across hospitals, clinics, and HCBS providers to share certain resources between them. This may include using a coordinated pool of workers, training, personal protective equipment, or other resources. The Department, in partnership with the Office of eHealth Innovation, will identify areas that would benefit from this approach and recommendations on how to pursue and implement it. The Department will then set up a pilot program by finding members and providers to test out the model. The Department will evaluate the pilot by analyzing whether the desired outcomes were achieved, interviewing participants, and providing final recommendations on next steps and sustainability.

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Initiative 1.05. - Establish a Training Fund

Note: As of December 2021, this project has incorporated project 3.03 Disability Cultural Competency Training for Behavioral Health Providers under the scope of its efforts.

Providing more training opportunities and incentives for workers to gain higher-level skills would promote greater retention within the workforce. The Department will establish a training fund targeted to high-demand jobs and to support specialization and advancement opportunities for the HCBS workforce, including the behavioral health workforce. Funds may be distributed directly to the prospective or current worker, to the employer to provide the training to their employees, or to a training provider. Additionally, funds may be used to expand standard training provider resources or trainer availability where gaps exist. This project will also develop a disability-specific, culturally competent curriculum that includes the different types of disabilities and incorporates people’s lived experiences to help providers understand diverse populations’ perspectives. The training will include information, examples, and skill-building activities on how best to serve the disability community. The goal of this fund is to provide short-term funding to incentivize and expand training opportunities for the HCBS workforce with the goal of increasing recruitment and retention.

Provider Training Fund Grant Recipients (to date)

GranteeTraining Title/TopicAward Amount
AbleLight, Inc.NADSP Certifications for DSPs$73,260
Adeo ColoradoCreating Cohesive Collaborative Teams
Brain Injury+: Diabetes, Dementia and more
Advanced Behavioral ResourcesRegistered Behavior Technician Training (RBT) with certification from the Behavior Analysis Certification Board (BACB).$33,500
AlfaBEST Home Care, LLCDCW Mentorship Program$8,800
Amity Healthcare Group, LLCAlzheimer’s and Dementia Caregiving at Home$77,198
Beken HoldingsCrucial Conversations$58,764
Blue Spruce Home Care, IncLGBT Diversity Training to care providers$45,298
Bonnie Be Bodywork, LLCMassage Therapist Training Project$61,963
Caring VoicesStaff Development to include: DBT, Trauma Informed Care, Cultural Competency, Mental Health Awareness, and signs of Suicide/Signs of Targeted Violence$33,774
Colorado Autism Consultants, LLCMentorship Training$99,993
Colorado Family CaregiversCNA training$79,200
Colorado Spirit Home Care, Inc.Managing Chronic Conditions$98,802
Common Roots, LLCTrain the Trainer: Sexuality for people with I/DD$1,095
Community Options IncChange Management, Emerging Leaders, Leadership Training$18,315
Developmental Disabilities Resource Center

National Association of Direct Support Professionals:

  • An Introduction to The NADSP Code of Ethics
  • Informed Decision Making: An Introduction
  • Creating a Culture of Competency
  • Code of Ethics: Train the Trainer Curriculum
  • Frontline Supervisor: Train the Trainer Curriculum
  • Informed Decision Making: Train the Trainer
Engage with Skills Training ProgramsEngage with® Older Adults at home Skills Training Programs$99,523
Grand Valley Behavior; Services and Consulting, LLCProtocol for Crisis Prevention$93,968
Interim Healthcare of Southeastern Colorado, Inc.

Training Homemakers to be:

  • Personal Care Workers
  • Personal Care Attendants
  • Health Maintenance Attendants
Monaco Adult Day Care, IncAdult Day Care Program for Members with Mental Health Diagnosis$39,386
Mountain Lane Home CareCNA training$89,100
NeuAbility FKA SCI Recovery ProjectAdaptive wellness training for CIH Waiver services$5,027
OvertureCollaborative Safety$96,800
Parker Personal Care HomesImproving the workforce through soft skill development, workplace culture support, and psychological and behavioral health training.$99,794
Promise AcademyRegistered Behavior Technician Training (RBT)$79,200
Resilient ColoradoResiliency Training$100,000
Second Home Day ProgramCrisis Prevention$100,000
Shared Touch, Inc.Active Shooter & Self-Defense Training$7,458
Skills Academy Vocational CenterTrauma Assumed Care$61,600
StarpointNADSP Code of Ethics Train-the-Trainer Curriculum$13,200
Supreme Health Care, LLCHome Care for Members with Mental Health Disorders$100,000
Tanner Autism Services of Colorado, LLCProtocol for Crisis Prevention$82,500
The Child and Family Therapy Center of Denver LLCBuilding Capacity and Effectiveness in HCBS Member Services$86,873
VitalHeartsSecondary Trauma Resiliency Training$100,000
Activity Options, LLCPerson Centered Training$50,813
Advanced Behavioral ResourcesCultural Sensitivity, Emotional Well-being, and Empowerment and Advocacy Training$59,400
Beo Personal CareCNA Certification$97,626
Colorado Behavior and Learning GroupInclusive Milestone and Development Training for Music Therapists$43,285
Consultants for Children, Inc.Child and Youth Mentor Training$93,500
Denver Home Healthcare, inc.Retention Through Culturally Sensitive Communication: Empowering Non-English and English-Speaking Caregivers$83,563
Developmental Disabilities Resource CenterPEAK Level 1 Comprehensive Training$6,671
Excellent Personal Home Care Health, IncHome Care Services for Clients with Mental Health Disorders$57,882
Grace Mountain, LLCProfessional Development Series for DCWs$24,200
Home Care and Hospice Association of ColoradoEnhancing Care Delivery: Person-Centered Care Training for Caregivers + Caregiver Mentorship and Certification Program$59,400
Integrated Therapy of Northern Colorado, LLCInclusive Milestone and Development Training$20,330
Personal Assistance Services of ColoradoResiliency Training for Caregivers$24,815
Resonate Music TherapyAdvanced Music Therapy Training Series$86,917
RevelProfessional Development Series: Learn It, See It, Practice It, Use It$97,900
Sunlight Home Health CareCaregiver Upskilling Series$70,994
Super Health Care, IncHow to Effectively Communicate with a Person with Mental Illness: Dos and Donts of Caring for Patients with Mental Illness$84,480
WisePlan to Placement and Say Yes! to Supported Employment$99,550
Total Distributed$3,159,873


Initiative 1.06. -  Career Pathways

The Department will establish income-based, affordable pathways to build career advancement opportunities for the healthcare workforce. The Department will partner with the Colorado Community College System, the Department of Higher Education, and the Department of Labor and Employment to work on career development pathways for direct care workers. This project will leverage the existing work within our sister agencies and incorporate the deliverable into ongoing initiatives.

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Initiative 1.07. - Public Awareness Campaign

The Department will launch a public awareness campaign about the value and importance of the direct care workforce. The campaign will garner workforce pride as well as greater respect and appreciation for these positions, which will ultimately help with recruiting and retaining individuals into the field.

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Initiative 1.09. - Workforce Compensation Research - Completed

Key Project Achievements and/or Activities:

The project achieved the creation of a key  Direct Care Workforce (DCW) Report.  This report provides demographic information on DCW workers nationally and supplies essential details regarding the concerns of Direct Care Workers, such as turnover rates and the absence of paid time off. The report provides insights into various state policies, such as paid sick leave, with specific mentions of states like Connecticut, Rhode Island, Vermont, Virginia, and New Mexico, which offers home health aide training and free in-house child care. Noteworthy programs like Minnesota's transportation support for DCWs are highlighted.

The report incorporates stakeholder feedback gathered from over 100 individuals across multiple sessions, indicating a strong demand for increased pay rates, better health insurance, financial assistance for housing, utilities, transportation, child care, and improved working conditions. Based on this input, recommendations were proposed for tiered compensation linked to competency programs and peer mentoring initiatives. Additionally, the report outlines workforce innovations, including comprehensive compensation packages, recruitment and retention strategies, and initiatives for addressing burnout and turnover in the healthcare sector.

Various states and local entities, such as California, Colorado, and Idaho, are mentioned for their innovative approaches to workforce housing solutions. The report concludes by addressing the challenge of the benefits cliff, which poses a significant barrier to financial stability and job security nationwide. It emphasizes the need for collaborative efforts across agencies and programs to address this issue effectively, although there are currently no specific implementations underway to tackle this challenge.

Summary / Project Outcome:

The project resulted in the creation of a DCW Report.

The DCW Report delves into national demographics and critical aspects of Direct Care Workers (DCWs), emphasizing turnover rates and the absence of paid time off. It highlights various state policies, such as paid sick leave, and showcases innovative programs like New Mexico's child care plan and Minnesota's transportation support for DCWs. Stakeholder feedback from over 100 individuals emphasized the need for increased pay rates, improved benefits, and support for housing, transportation, and child care. Recommendations include tiered compensation linked to competency programs and peer mentoring, along with best practices for recruitment, retention, and workforce housing solutions.

This report underscores the need for comprehensive strategies to address workforce challenges, improve compensation and support systems, and enhance the quality of care provided to individuals across Colorado's healthcare sector.

External Facing Reports/Websites:

Direct Care Workforce: Innovative Compensation Recommendations Report 

✅Initiative 1.08. - Home Health Delegation - Completed

Date Completed: November 2023

One way to expand the workforce in the home health field is to ensure that all workers are working at the top of their licenses. For example, Registered Nurses (RNs) may delegate skilled tasks to a Certified Nurse Aide (CNA) that they otherwise would not be able to perform. An RN provides training to the CNA to perform the skilled task and the task is then delegated to them, allowing a CNA to practice to the top of their license and potentially increase their wages, leading to longer-term retention. The Department will explore opportunities for further developing the home health workforce. This includes an environmental scan to identify care deserts, a survey to understand barriers, and subsequently, implementing solutions to increase delegation to this workforce, thereby enabling increased wages, retention, and recruitment. In addition, the Department will provide incentive payments to home health agencies that provide innovative models of care, such as increased delegation.