Perspectives in Policy - Direct Care Workforce

Issue 2, 12/4/2012

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Perspectives in Policy - Direct Care Workforce

ErinIowa, like the nation, is facing a mounting challenge to meet the needs of an aging population and ensure access to support services and choice for people of all abilities. Direct care professionals (DCPs) play a critical role in supporting the independence, daily living, and health of Iowans. Direct care has taken center stage in policy discussions as Iowa works to implement recommendations of the Direct Care Worker Advisory Council.

The Iowa General Assembly charged the Advisory Council to develop recommendations that would ensure a stable and qualified direct care workforce.

Take a look at the challenge before us:

• DCPs comprise the single largest profession in Iowa, estimated at 73,000.

• Despite their size, demand for direct care services isincreasing at rates exceeding capacity of the workforce.

• Workforce projections indicate that Iowa will need an additional 12,000 new DCPs by 2018.

• With an estimated statewide average turnover rate of 64% annually at a cost of $3,839 per worker, turnover in this workforce cost an estimated $189 million in 2011 – this is troubling both in terms of cost and the impact on consumers when workers leave.

The bottom line is this – if direct care is not a career that people choose and stay in, we will not be able to meet the demand for their services.Working to balance the interests of consumers, DCPs, employers and education providers, the Advisory Council conducted research, outreach and deliberated solutions. The Advisory Council recommended the development of career pathways and standards for education of DCPs, all to be governed by a certification board. Key components include:

• Required core training of six hours and certification for paid direct care professionals

• Paid family members will be exempt

• Training will be offered online, through employers, community colleges and others – the goal is to provide choice and offer flexibility   • Many online programs, including the College of Direct Supports, could be recognized

• Curriculum developed by the state will be available for free to qualified instructors

• Existing workers will be transitioned or “grandfathered” into the new system

The goals are to reduce the costs of turnover, improve recruitment and retention, to address growth and demand for workers and improve the quality of and access to direct care services. To ensure these results are achieved, recommendations are currently being piloted by employers and community colleges through a federal grant to the Iowa Department of Public Health (IDPH). Iowa is one of just six states developing a national model for direct care worker education and credentialing.

This effort has been shaped and strengthened by the contributions of providers, direct care professionals, consumers and many others. IDPH welcomes your input and contributions. To learn more or become involved, visit or contact

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Provider & Workforce Advocate Perspectives

Everyone that we spoke with while preparing this issue of Perspectives in Policy agreed that Iowa’s direct care workforce is an invaluable resource that is essential to the delivery of quality health care and human services to individuals of all abilities. 

Providers and other advocates for direct care workers have varying perspectives on how best to professionalize the workforce and give direct care workers a career path that is credible, professional and sustainable.

Di Findley, Executive Director of the Iowa Care Givers Association, an advocate for direct care workers, is a strong supporter for creation of a governing board at the Iowa Department of Public Health (IDPH) to “provide the direct care workforce the professional status they deserve, the state with the infrastructure needed to ensure a stable direct care workforce and consumers and their families the assurance that a well-educated and skilled direct care workforce will be there to provide high quality services when and where they are needed.”

The proposed board and certification process would increase the educational standards for all direct care workers and provide opportunities for specialization and career growth.  The Iowa Caregivers Association is a supporter and proponent of the proposed legislation to create a board of Direct Care Workers in Iowa.  Some providers though have expressed concern that the new requirements may prove burdensome to direct care workers and reduce or even eliminate the pool of part-time workers employed by many community providers. 

The Iowa Association of Community Providers echoed those concerns in a response to state lawmakers that warned that the legislation created a duplicative training and certification process that would increase the costs of community based services, provide less flexible care for those receiving services and decrease the available workforce.

Delaine Peterson, Executive Director of the Arc of East Central Iowa, shared her concerns about the legislation. “I am absolutely 100 percent in favor of having every opportunity for direct care workers to be professionalized; however, my concern in reading the direct caregiver law as a provider and a parent of two children with disabilities is that the law is very medical in nature.” Others share Peterson’s concern and believe the proposed law focuses more on those direct care workers working in the nursing home setting, for example, rather than working with persons with disabilities and their families.

“We are never going to make people well—we are going to make them accepted and accommodate them inside a community. Furthermore, the legislation put a lot of the responsibility on the backs of the already underpaid direct care workers. I think we need to focus more on providers setting core standards but not putting so much responsibility or delaying people’s access to training because they have to pay for it themselves,” Peterson says.

No one denies direct care workers are “overworked and underpaid” in Iowa. Nevertheless, there is little data to demonstrate that passing legislation to create a Board of Direct Care Workers will result in increased pay, especially since many of the factors determining the pay of direct care workers is controlled by state and federal reimbursement streams like Medicaid and Medicare.

Amy Wallman Madden and Linda Matkovich share interest in the issue of professionalizing the direct care workforce as parents of children with disabilities and the co-founders of Honoring Opportunities for Personal Empowerment (HOPE), a provider group based in Des Moines. Matkovitch noted, “my daughter has received services in different settings in different counties across Iowa and we noticed over the years that there was a glaring lack of consistency in training from county-to-county and a lack of value for the direct care workers themselves.”

Wallman Madden continued, “the largest component to helping our clients become more independent and rely less on paid support staff is simply valuing our direct care workers as professionals and treating them with the respect they deserve.”

Update on the Direct Care Workforce Legislation: The legislation to start a Board of Direct Care Workers failed to pass during the 2012 session, so direct care workers will not be licensed by the state. However, the direct care worker initiatives did see a bump in funding for scholarships, recruitment and retention efforts. Efforts to create a State Licensure Board will return next year in the 2013 legislative session.

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A Parent's Perspective

RachelOur daughter was placed in our home, as a foster child, when she was 9 days old.  She had been exposed to methamphetamine and, as a result, was diagnosed with cerebral palsy which requires use of a wheelchair to ambulate.  Rachel has no expressive language, ability to feed, bathe, clothe, or toilet herself. 

However, she understands everything you say and wants the same thing out of life as any typical 16 year old.  Her world involves YouTube, music, movies, church, school, miracle league baseball, swimming and most importantly trips to Dairy Queen.

Caring for Rachel is a 24/7 job. There are no days off, no ability to call in sick, no vacations and certainly much less rest than one would expect with a 16 year old. While we provide the majority of her care we simply could not maintain that level of intensity/frequency ourselves.  Without help from direct care professionals Rachel would not be able to live at home.  As much as we love her and are committed to her it really does take a “village” to meet her needs so she can remain at home, where she belongs.  It is less costly and provides her with a much better life than if she was living in an institutional setting.

Only workers with specialized knowledge are allowed to care for Rachel.  Her safety and quality of life depends on those who care for her.  It is past time Iowan’s recognize the need for all direct care professionals to be adequately trained and compensated so those who want to live at home can and be secure in the knowledge they are well cared for.  This will only happen with the creation of a statewide board that would develop minimum training standards and certification.

 - Jim Pender, Father of Rachel        

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A Direct Care Worker's Perspective

FranI have a great deal of passion and love for the work I do in direct care. It is sad, but a good part of the public world does not view direct care as a valued profession.  As a result, so many direct care workers do not feel appreciated or valued for who they are and the work they do.  For me, and many of my co-workers, direct care is far more than “just a job.”  It is our chosen profession. 

To perform direct care that is real quality, takes professional skills. I want the state of Iowa to view direct care as a recognized career. What better way to do that then to create a Board of Direct Care Professionals within the IDPH.

This Board would set the rules, expectations, and standards for the profession of direct care.  It would provide direct care workers opportunities to specialize in various areas of care such as Alzheimer’s, hospice, mental health, brain injury and others. It would also make it so much easier for me and other direct care workers to move from one type of direct care to another without losing credibility—such as moving from nursing home care to hospice care, or moving from home care to nursing home care. My credibility would travel with me. 

The only objection to the creation of a Board of Direct Care Professionals may be that I, as a Direct Care Worker, would have to pay a fee to maintain my credentials. Paying a fee is part of taking some responsibility for my own credentials and profession. 

What I and so many others do in direct care is vital to the care, welfare, safety, and security of all people in the state. The public at large would start to view us as skilled caregivers who can be trusted to perform direct care tasks in a responsible, skilled, and professional manner.  It would also help make sure those of us who lack the skills to perform direct care or do not treat those they service with dignity and respect would not remain in the profession.

- Fran Mancl is a CNA in Dubuque, Iowa who has worked with Iowans with disabilities.


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