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.
View Stakeholder Engagement Opportunities related to this project
✅Initiative 1.02. - Direct Care Workforce Data Infrastructure - Completed
Key Project Achievements and/or Activities:
The DCW Survey successfully engaged direct care workers in 60 of Colorado’s 64 counties each year, demonstrating broad representation within the direct care workforce. Participation increased annually, reflecting growing engagement among Direct Care Workers (DCWs). Consistent insights revealed key concerns, such as limited access to benefits, while highlighting successes: over 85% of respondents expressed satisfaction with their work, and more than 55% reported contentment with their wages, indicating a low likelihood of job turnover in the coming year.
Providers supporting older adults and individuals with disabilities reported a turnover rate of 49.4% among their direct care workers. Notably, 47% of providers indicated they offer pay incentives or referral bonuses to encourage new recruits and 79% of agencies utilized DCW Ladders to retain highly skilled workers in DCW roles. There was also a low vacancy rate reported for full-time (7%) and part-time (6%) employees in the aging and disability workforce. Furthermore, participating in the SotW-AD Survey allowed HCPF to compare the providers supporting older adults and individuals with disabilities with providers supporting adults with intellectual and developmental disabilities, and note any differences and similarities in the workforces. To view the comparison of results, visit the At-A-Glance report.
Comprehensive reports detailing these findings are or will be available on our website.
The Self Direction Evaluation had successful outreach with current Members, advocacy groups, established collaboratives, community associations + potential providers, current providers, financial management service vendors, and subject matter experts. There was a large scope of varied engagement (surveys, interviews, presentations, workgroups) that valued participation and input. This feedback was vital to identify a recommended outcome and roadmap for Colorado to expand self direction.
Summary / Project Outcome:
Over three years, the project successfully administered surveys targeting direct care workers (DCWs) and the State of the Workforce for Aging and Disability providers (SotW-AD). The initiative aimed to enhance data infrastructure to assess the supply and demand for DCWs and evaluate the effectiveness of various investment strategies on recruitment, retention, and turnover.
Two key surveys were developed:
State of the Workforce Survey: This survey focused on HCBS waiver providers and gathered data on DCW numbers, turnover rates (just under 50%, with over 75% being voluntary), employment status, vacancy rates, and wages. Key demographics showed that 73% of Colorado’s workforce identify as female, 49% work part-time, and 83% are employed by private for-profit agencies.
Direct Care Worker Survey: This survey assessed worker satisfaction regarding compensation, benefits, career advancement, training, and workforce challenges. Findings indicated that 89% of DCWs find their job enjoyable, and more than half are unlikely to leave their positions in the next year. While many express satisfaction with their wages, most lack access to health benefits or retirement preparation.
By administering these surveys multiple times, the project generated comparative data, deepened understanding of the workforce landscape, and provided actionable insights for addressing workforce issues in the DCW sector. Overall, the findings significantly contribute to both short-term and long-term workforce strategies.
Additionally, the Mission Analytics Self-Directed Evaluation evaluated options for expanding self-direction in Colorado and made recommendations on the most effective authorities to achieve this.
External Facing Reports/Websites:
DCW Survey Webpage - Coming soon!
✅Initiative 1.03. - Standardized Core Curriculum & Specialization - Completed
Key Project Achievements and/or Activities:
The project successfully developed a comprehensive curriculum for direct care workers, featuring 19 core modules and 12 specialized modules. These training materials cater to those providing homemaker services and personal care support. The core modules cover agency orientation and meet the training needs of new personal care workers within their first 45 days, while the specialized modules address a range of care needs.
Extensive stakeholder engagement was a cornerstone of this project. An advisory group of diverse stakeholders helped create and vet the modules. Over three years, 21 listening sessions and 10 pilot tests were conducted, incorporating feedback from members, families, advocates, former direct care workers, and providers across Colorado. HCPF launched a pilot incentive program to encourage interest in the curriculum and gather feedback from HCBS, LTHH, and PACE providers, with 20 modules available for review on the Direct Care Careers site. Overall, out of 256 unique reviews, the content was rated effective by at least 90% of the participants. This collaborative approach ensured the training materials are effective and relevant, enhancing the orientation and training of direct care workers and ultimately improving the quality of care for members statewide.
Summary / Project Outcome:
This project successfully developed a standardized curriculum and training program for homemakers and personal care workers, establishing quality standards and enhancing specialized qualifications linked to wage increases. Designed to be adaptable to various settings and populations, these training materials ensure relevance across different employer, member, and worker needs. Utilizing a 'universal worker' structure, the project created adaptable training materials available for free both in-person through a train-the-trainer model and online. Certificates from these trainings can be transferable across employers, fostering continuity and flexibility within the workforce.
The project prioritized extensive stakeholder engagement to ensure the training materials are effective, relevant, and responsive to community needs. The training materials are now hosted on the Direct Care Careers website, ensuring sustainability and ongoing management for the benefit of direct care workers statewide.
External Facing Reports/Websites:
All of the training modules will be available on Direct Care Careers website.
✅Initiative 1.04. - Resource and Job Hub - Completed
Key Project Achievements and/or Activities:
The creation of the Direct Care Careers (DCC) hub is a step towards continued growth in the Direct Care Workforce. By providing a centralized platform for job search, employer matching, and access to resources, the DCC aligns with broader efforts to support the direct care workforce. The training modules and certification tracking feature will not only offer to streamline recruitment but will also improve the quality of care delivered to waiver recipients. Moreover, the collaborative nature of this project underscores the importance of partnerships between government entities, vendors, and states in addressing the inherent challenges in the direct care workforce.
Summary / Project Outcome:
The Direct Care Careers (DCC) website, created by the Department of Health Care Policy & Financing (HCPF), has successfully launched a user-friendly online hub tailored to the needs of direct care workers (DCWs) and employers. The DCC not only simplifies job search and recruitment processes but also supports continuous learning and professional development within the direct care workforce
External Facing Reports/Websites:
✅Initiative 1.10. - Rural Sustainability and Investment - Completed
Key Project Achievements and/or Activities:
The project successfully created a public Geographic Information System (GIS) tool that visually maps the availability of services like Homemaker, Personal Care, and Respite across the state, showing how these services align with the needs of members. This tool also identifies areas with insufficient services, referred to as care deserts. Through extensive stakeholder engagement and research, we gathered valuable insights into how to enhance access to care for members. This information will help guide actions and supports designed to address service gaps and improve overall member access to essential services.
Summary / Project Outcome:
The project has made significant progress to strengthen care access and address service delivery gaps. Through this project, a heat map tool was developed that identifies areas with limited access to HCBS waiver service providers in both rural and urban settings, which will be updated annually. The tool is expected to be publicly launched later in 2024 and will be available on HCPF’s website, with links across various HCPF pages to maximize accessibility.
Stakeholder engagement has been a crucial part of this work, involving over 125 stakeholders through various meetings and one-on-one interviews with rural providers. This feedback has been essential in shaping the identified strategies for improving healthcare access and reimbursement structures.
The project team is currently reviewing the gathered insights to develop strategies for adjusting rates based on geographic location. This process involves assessing different approaches, weighing their advantages and disadvantages, and considering budgetary impacts. HCPF's aim is to use these findings to guide future decisions and discussions.
Additionally, this project explored how other communities share resources and manage overhead costs to support rural providers. While the information was somewhat limited, the team was able to offer several practical suggestions. These will be shared with providers through various platforms and collaborative groups to explore and implement effective solutions.
Overall, this project is focused on enhancing healthcare access and developing strategies tailored to the diverse needs of Colorado's communities.
External Facing Reports/Websites:
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.
- View Direct Care Workforce Collaborative Stakeholder Engagement Opportunities related to this project
- View Trauma Informed Training related to this project
- View the Prader-Willi Training Series Stakeholder Engagement related to this project
- View information about grant funding available for providers related to this project
Provider Training Fund Grant Recipients (to date)
| Grantee | Training Title/Topic | Award Amount |
|---|---|---|
| AbleLight, Inc. | NADSP Certifications for DSPs | $73,260 |
| Adeo Colorado | Creating Cohesive Collaborative Teams Brain Injury+: Diabetes, Dementia and more | $78,782 |
| Advanced Behavioral Resources | Registered Behavior Technician Training (RBT) with certification from the Behavior Analysis Certification Board (BACB). | $33,500 |
| AlfaBEST Home Care, LLC | DCW Mentorship Program | $8,800 |
| Amity Healthcare Group, LLC | Alzheimer’s and Dementia Caregiving at Home | $77,198 |
| Beken Holdings | Crucial Conversations | $58,764 |
| Blue Spruce Home Care, Inc | LGBT Diversity Training to care providers | $45,298 |
| Bonnie Be Bodywork, LLC | Massage Therapist Training Project | $61,963 |
| Caring Voices | Staff 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, LLC | Mentorship Training | $99,993 |
| Colorado Family Caregivers | CNA training | $79,200 |
| Colorado Spirit Home Care, Inc. | Managing Chronic Conditions | $98,802 |
| Common Roots, LLC | Train the Trainer: Sexuality for people with I/DD | $1,095 |
| Community Options Inc | Change Management, Emerging Leaders, Leadership Training | $18,315 |
| Developmental Disabilities Resource Center | National Association of Direct Support Professionals:
| $53,859 |
| Engage with Skills Training Programs | Engage with® Older Adults at home Skills Training Programs | $99,523 |
| Grand Valley Behavior; Services and Consulting, LLC | Protocol for Crisis Prevention | $93,968 |
| Interim Healthcare of Southeastern Colorado, Inc. | Training Homemakers to be:
| $21,516 |
| Monaco Adult Day Care, Inc | Adult Day Care Program for Members with Mental Health Diagnosis | $39,386 |
| Mountain Lane Home Care | CNA training | $89,100 |
| NeuAbility FKA SCI Recovery Project | Adaptive wellness training for CIH Waiver services | $5,027 |
| Overture | Collaborative Safety | $96,800 |
| Parker Personal Care Homes | Improving the workforce through soft skill development, workplace culture support, and psychological and behavioral health training. | $99,794 |
| Promise Academy | Registered Behavior Technician Training (RBT) | $79,200 |
| Resilient Colorado | Resiliency Training | $100,000 |
| Second Home Day Program | Crisis Prevention | $100,000 |
| Shared Touch, Inc. | Active Shooter & Self-Defense Training | $7,458 |
| Skills Academy Vocational Center | Trauma Assumed Care | $61,600 |
| Starpoint | NADSP Code of Ethics Train-the-Trainer Curriculum | $13,200 |
| Supreme Health Care, LLC | Home Care for Members with Mental Health Disorders | $100,000 |
| Tanner Autism Services of Colorado, LLC | Protocol for Crisis Prevention | $82,500 |
| The Child and Family Therapy Center of Denver LLC | Building Capacity and Effectiveness in HCBS Member Services | $86,873 |
| VitalHearts | Secondary Trauma Resiliency Training | $100,000 |
| Activity Options, LLC | Person Centered Training | $50,813 |
| Advanced Behavioral Resources | Cultural Sensitivity, Emotional Well-being, and Empowerment and Advocacy Training | $59,400 |
| Beo Personal Care | CNA Certification | $97,626 |
| Colorado Behavior and Learning Group | Inclusive 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 Center | PEAK Level 1 Comprehensive Training | $6,671 |
| Excellent Personal Home Care Health, Inc | Home Care Services for Clients with Mental Health Disorders | $57,882 |
| Grace Mountain, LLC | Professional Development Series for DCWs | $24,200 |
| Home Care and Hospice Association of Colorado | Enhancing Care Delivery: Person-Centered Care Training for Caregivers + Caregiver Mentorship and Certification Program | $59,400 |
| Integrated Therapy of Northern Colorado, LLC | Inclusive Milestone and Development Training | $20,330 |
| Personal Assistance Services of Colorado | Resiliency Training for Caregivers | $24,815 |
| Resonate Music Therapy | Advanced Music Therapy Training Series | $86,917 |
| Revel | Professional Development Series: Learn It, See It, Practice It, Use It | $97,900 |
| Sunlight Home Health Care | Caregiver Upskilling Series | $70,994 |
| Super Health Care, Inc | How to Effectively Communicate with a Person with Mental Illness: Dos and Donts of Caring for Patients with Mental Illness | $84,480 |
| Wise | Plan to Placement and Say Yes! to Supported Employment | $99,550 |
| Total Distributed | $3,159,873 | |
✅Initiative 1.06. - Career Pathways - Completed
Key Project Achievements and/or Activities:
Career Pathways: The project developed 20 soft-skill training modules and five healthcare job shadowing modules, designed with accessibility and translated into five languages for current and prospective direct care workers. The job shadow videos include interviews showcasing real work experiences and skills. Additionally, over 60 roles were mapped across 20+ career pathways, each offering at least two steps for advancement.
Stakeholder Engagement: The project involved engagement with 145 stakeholders through interactive presentations on four (4) occasions. Stakeholder feedback was used to select in-demand healthcare roles and learn about what important factors needed to be included when creating career pathways for direct care workers.
Summary / Project Outcome:
The need to recruit and retain direct care workers is critically important. This project aimed to create affordable, income-based career pathways in healthcare, focusing on skills development and interactive training modules for direct care workers. In partnership with the Colorado Department of Labor and Employment (CDLE) and the Colorado Department of Higher Education (CDHE), it identified key areas of interest for career advancement, such as medical, technical, and community support roles, each with "Area of Interest Info Sheets" that provide job information, pay ranges, growth projections, required education, and resources for workers. Additionally, 20 interactive soft skills training modules and five job shadowing videos were created in multiple languages to enhance recruitment and retention, each designed to engage new and current healthcare workers through accessible, interactive learning experiences.
External Facing Reports/Websites:
Landing page for career pathways maps, one-pagers, and info sheets coming soon!
✅Initiative 1.07. - Public Awareness Campaign - Completed
Key Project Achievements and/or Activities:
The project set out to create a public awareness campaign to bring more awareness of the direct care workforce and what they do. The campaign began with research, content development, and message testing involving interested stakeholders. Using social media, TV, radio, and print ads, the campaign engaged in a broad attempt to reach a large audience across the state. After launching the campaign in November 2023, routine feedback and tweaks were made to ensure a robust campaign through its end in February 2024. Overall, the goal of this project was to help people see how important this workforce is to the state and to encourage more people to join this field. While the campaign has wrapped up, there remains a website with the materials to be used for recruitment efforts by HCPF and other interested stakeholders.
Summary / Project Outcome:
The 1.07 HCPF Public Awareness Campaign was launched to aid in addressing the critical shortage of direct care workers (DCWs) in Colorado and to raise awareness about their crucial role in providing care. Extensive planning and research were conducted to understand public perceptions and inform the campaign's strategies. The research revealed a lack of awareness and misconceptions about DCWs, prompting the need for targeted messaging.
Circuit Media, in collaboration with HCPF, developed a comprehensive campaign aimed at challenging stereotypes, promoting diversity within the direct care workforce, and showcasing the positive impact of DCWs on individuals' lives. The campaign utilized various media channels, both traditional and digital, to reach a wide audience across the state.
Continuous monitoring and optimization efforts were employed throughout the campaign, with regular reports providing real-time data for adjustments in messaging and media placements. Stakeholder engagement sessions and collaborative meetings further contributed valuable feedback and insights to refine campaign strategies.
Overall, the campaign sought to elevate the profile of DCWs and highlight their invaluable contributions to society, with the ultimate goal of addressing the workforce shortage and improving the quality of care in Colorado.
External Facing Reports/Websites:
The campaign videos, infographics, flyers, and social media advertisements can be found on the Direct Care Spotlight webpage .
✅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.