Long-Term Services and Supports in Baltimore

April 2023 / Abell-Supported Research / Workforce Development
Close-up of home caregiver and senior holding hands.
A framework for improving job quality and creating a highly trained direct care and services workforce.

The current tight labor market can be seen and felt throughout the United States, from restaurants and retail stores to doctors’ offices and daycare centers. In some sectors of the labor force, however, short staffing is much more than an inconvenience.

One such sector is the direct care and services workers (DSWs) who serve older adults and individuals with disabilities in long-term services and supports (LTSS) settings. Staffing challenges have vexed nursing homes, assisted living facilities, and home- and community-based care settings since before the pandemic. These challenges are not likely to abate until systemic solutions are identified and implemented.

As this report from the Maryland Regional Direct Services Collaborative illustrates, the DSWs who work in 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:

  1. 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. Further, in some LTSS settings, the practice of misclassifying workers as independent contractors denies them employment benefits such as earned sick or vacation leave or extra pay for overtime hours.
  2. 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.
  3.  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.
  4. 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.
  5. 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 report offers several promising practices and potential solutions to help improve job quality for direct care and services professionals and resolve the workforce crisis in Baltimore City and beyond.