Strengthen the Workforce & Enhanced 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.” 

These trainings 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. These trainings will ‘live’ on the newly created Resource & Job Hub (initiative 1.04) for sustainability and ongoing management.

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Initiative 1.04. - Resource & 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.

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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

Wages are not the only consideration in someone’s decision to work in a certain field. The Department will research innovative opportunities for increasing compensation for the HCBS workforce in other ways. The Department will identify ways to provide childcare for direct care workers; explore funding for shift differentials; and identify other practices that could better support low-income workers, such as hiring retention specialists or case managers within home care agencies whose job is to support the frontline workers.

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Initiative 1.08. - Home Health Delegation

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.