Sustainability of Idaho's Direct Care Workforce (Idaho Office of Performance Evaluations)

February 2023
Sustainability of
Idaho’s Direct Care
Workforce
Office of Performance Evaluations

Idaho Legislature
Promoting confidence and accountability in state government

Established in 1994, the legislative Office of Performance
Evaluations (OPE) operates under the authority of Idaho Code
§§ 67-457–464. Its mission is to promote confidence and
accountability in state government through an independent
assessment of state programs and policies. Professional
standards of evaluation and auding guide our work.
Joint Legislative Oversight Committee

2023-24
The eight-member, equally bipartisan Joint Legislative Oversight
Committee (JLOC) selects evaluation topics; OPE staff conduct
the evaluations. Reports are released in a public meeting of the
committee. The findings, conclusions, and recommendations in
OPE reports are not intended to reflect the views of the Oversight
Committee or its individual members.
Senators
Senator Melissa
Wintrow (D) and
Representative Melissa Wintrow C. Scott Grow Dave Lent James D. Ruchti
David M. Cannon
(R) cochair the Representatives
committee.
David M. Cannon Douglas T. Pickett Ilana Rubel Steve Berch
2
From the director
February 15, 2023
Members
Joint Legislative Oversight Committee
Idaho Legislature
More than 33,000 people with disabilities and older adults in 954 W. Jefferson Street
Idaho rely on the direct care workforce at home and in their Suite 202
communities. Direct care workers help with essential daily tasks Boise, Idaho 83702
like eating, getting dressed, and building skills for independent Ph. 208.332.1470
living. legislature.idaho.gov/ope/
Since private insurance and Medicare only pay for direct care in
certain short-term situations, people with chronic or long-term Formal responses
needs often end up relying on Medicaid. According to economists from the Governor,
we worked with, the state is creating price ceilings that act as a the Department of
wage cap for direct care workers. Health and Welfare,
the Idaho Council
There is a nationwide shortage of direct care workers, but we on Developmental
found that state policy decisions have contributed to a worse Disabilities, the
situation in Idaho. The state would need 3,000 more workers to Idaho Commission
get up to national staffing levels and that number is expected to on Aging, and the
more than triple over the next decade. State Independent
Living Council are in
Direct care workers reported being drawn to the field because
the back of the
they like helping people. But high wages offered elsewhere are
report.
hard to ignore, especially when direct care is often emotionally
and physically taxing. We found a vicious circle of high turnover.
As people leave direct care, remaining workers take on more
responsibility and feel guilty about not being able to do even more
to help the people they support.
Our report outlines several recommendations for the Division of

Medicaid to improve their rate-setting process and support other
efforts to improve sustainability of Idaho’s direct care workforce.
Sincerely,
Rakesh Mohan, Director

3
Contents
Page
Executive summary................................................................. 5
1. Introduction ...................................................................... 8
2. Is there a shortage of direct care workers? ....................... 14
Amanda Bartlett,
Ryan Langrill, and 3. What is causing the shortage? .......................................... 20
Sasha O’Connell
conducted this
evaluation. 4. How does the shortage affect Idahoans? .......................... 29
Lauren Bailey 5. Why is the shortage a state policy concern? ..................... 38

copyedited the
report.
6. Recommendations ............................................................ 50
Bob Thomas of
Robert C. Thomas
and Associates
provided a quality
control review. Appendices
A. Request for evaluation ...................................................... 62
B. Evaluation scope ............................................................... 65
C. Methods ............................................................................ 66
Responses to the evaluation ................................................... 73
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Sustainability of Idaho’s Direct Care Workforce
Executive summary
Direct care is an interdisciplinary field that encompasses a wide

range of services and supports including teaching, nursing,
home maintenance, transportation, dietary support, counseling,
occupational therapy, and physical therapy. In Idaho, more
than 33,000 people with disabilities and older adults rely on the
direct care workforce to maintain a healthy and independent
life at home and in their communities.
Concern about the direct care workforce prompted the request

for this evaluation. The request described a dire situation where
a lack of workers led to declining health, unmet medical and
personal care needs, strain on families, and relocation to
institutional care. In March 2022, the Joint Legislative
Oversight Committee directed our office to evaluate how Idaho
can create a sustainable direct care workforce.
We used data from multiple independent sources to answer a

series of questions about the direct care workforce.
Is there a shortage of direct care workers?

Yes. We conservatively estimated that Idaho is about 3,000
workers, or 13 percent, short of national staffing levels. The
shortfall has slowly grown since 2012. By 2032, the shortfall is
expected to grow to 9,500. The shortage was worse in North
Idaho and among the counties that border Washington and
Oregon. The shortage was also worse in industry settings that
were more reliant on Medicaid than in settings that have more
diverse funding sources.
What is causing the shortage?

Workers reported that low pay was the main reason they did
not intend to keep working in direct care. We conducted a
survey of direct care workers and received 782 responses. Direct
care workers reported that they were drawn to the field because
they wanted to help other people, but that the work was
emotionally and physically taxing. The typical nursing assistant
5
in Idaho received $14.16 per hour, while other direct care
workers received $11.49 per hour according to 2021 data from
the U.S. Bureau of Labor Statistics. A nursing assistant could
earn an average hourly wage of $19.64, a 39 percent increase, by
leaving direct care while other types of workers could earn
$15.68, a 36 percent increase.
Medicaid is the
primary payer for Why is this a policy concern for Idaho?
direct care Medicaid is the primary payer for direct care supports and
services and services, and Idaho’s Medicaid rates do not support sustainable
competitive wages for direct care workers. Medicaid creates a
supports.
price ceiling that acts as a wage cap for direct care workers.
Medicaid became the primary payer of direct care services for

two reasons. First, Idaho has a long history of offering state
support to older adults and people with disabilities. The state
consolidated many of these supports under the Medicaid
program. Historically, the state provided direct care in
institutional settings such as skilled nursing facilities and
intermediate care facilities. Beginning in the 1980s and through
today, home- and community-based services were incorporated
into Medicaid to improve quality, person-centered care while
saving money by providing a less expensive alternative to
institutional care.
When people
Second, private insurance plans and Medicare typically do not
need long-term, cover long-term, direct care services though they may cover
direct care hospice or short-term supports needed because of an acute
services they pay medical condition. Supplemental long-term care plans exist in
out of pocket the private market, but these plans are cost-prohibitive for most
unless or until people. That means when people need long-term, direct care
they qualify for services they typically pay out of pocket unless or until they
qualify for Medicaid.
Medicaid.
Today, Idaho has designed its program making choice a
fundamental element of how Medicaid balances quality with
efficient and economical care. For this model to work, people
who rely on direct care must be able to choose the correct
provider, businesses must be able to retain and recruit the right
workers, and the Division of Medicaid must be able to measure
access, quality, economy, and efficiency in a way that ensures the
system remains in balance.
6
We found that the Division of Medicaid’s rate-setting process is a

major driver of the worker shortage and undermines the state’s The Division of
ability to achieve its goals because Medicaid’s rate-
people who rely on direct care often feel that they must setting process is
settle for lower service quality or care provided in a major driver of
an institution; the worker
when staffing issues arise, people who rely on direct care shortage.
services may not have another support person to
help which can create troubling and dangerous
situations;
businesses feel they must settle for applicants with fewer
qualifications or keep poor-performing workers
longer than they would like; and
workers feel they have no choice but to leave direct care
because of low wages.
The division does not have good systems for measuring how rates
affect access to care. The division counts complaints and tracks
the number of providers, while businesses limit access through
waitlists, declining new clients, and providing fewer services.
How can the state support a more sustainable direct care

workforce?
The most straightforward strategy the state can employ for a
sustainable workforce is to ensure that the rate-setting process
supports competitive wages by
Medicaid rates
setting wage targets using a composite of similar and
competitive occupations, should support
competitive
adjusting the rates more frequently to keep in alignment
wages and be
with the wage targets, and
adjusted more
considering region-specific rates to better account for frequently.
different market drivers across the state.
The Department of Health and Welfare could also support

current efforts to make training more accessible and develop a
career ladder for direct care workers. Finally, we reemphasize the
importance of recommendations made in our 2022 report,
Medicaid Rate Setting, because this evaluation illustrated the
continuing consequences of not having adequate management
capacity in the Division of Medicaid.
7
1 Introduction
Though often overlooked, caregiving is a crucial part of daily life.

We all participate in the rituals of feeding, clothing, cleaning,
coaching, teaching, healing, protecting, and supporting. We care
for ourselves. We care for one another.
Most caregiving is unpaid. However, demographic changes and

shifts in our state’s economy impact our ability to rely on unpaid
care. The need for caregiving has increased because Idaho’s
population has aged and the number of people with disabilities
has grown over the past ten years, as shown in exhibit 1. About
one in five adults in the United States provides unpaid care to
another adult.1 These people face added pressure to maintain
paid employment as housing costs and inflation rise. A 2020
study by AARP and the National Alliance for Caregiving found
that about 61 percent of people who provide unpaid care to adults
also had paid employment. They spent between 20—30 hours a
week providing unpaid care.2
1. AARP and National Alliance for Caregiving, Caregiving in the U.S.

at 9 (May 2020).
2. AARP and National Alliance for Caregiving, Caregiving in the U.S.
2020: A Focused Look at Family Caregivers of Adults Age 50+ at 27, 40
(November 2020).
8
Exhibit 1
In Idaho, the number of older adults and people with
disabilities grew faster than the workforce.
Change in Idaho’s demographics between 2010 and 2020.
2010 2020 % Change
Median age 34.6 37.1 7%
People in the workforce 761,970 894,850 17%
Total population 1,570,750 1,847,770 18%
People with a disability 195,750 233,480 19%
People 65 years and older 196,130 301,200 54%
Source: Office of Performance Evaluations' analysis of data from the U.S. Census
Bureau and U.S. Bureau of Labor Statistics.
Direct care workers are paid caregivers who assist older adults Direct care
and people with disabilities with essential, daily tasks. Direct care workers assist
is complementary to and distinct from other fields, such as
older adults and
mental and physical health and social services. In Idaho, direct
care is an interdisciplinary field that is not well-defined. Direct people with
care workers have a variety of job titles, including the following: disabilities with
essential, daily
caregiver, caretaker, care provider, or care support staff
tasks.
certified nursing assistant
community support specialist or worker
developmental therapist or technician
direct care professional, provider, or support staff
direct service professional or staff
direct support professional or staff
home health or home care aide
in-home aide
personal care assistant, attendant, or provider
skills instructor or trainer
9
Exhibit 2
Direct care is an interdisciplinary field.
A wide variety of skill sets and knowledge fall within the scope of
direct care.
Source: Office of Performance Evaluations' adaptation from President’s

Committee for People with Intellectual Disabilities 2017 Report to the President:
America’s Direct Support Workforce Crisis: Effects on People with Intellectual
Disabilities, Families, Communities and the U.S. Economy, Figure 1 at 16,
available at https://acl.gov/sites/default/files/programs/2018-02/2017%
20PCPID%20Full%20Report_0.PDF
10
Legislative interest
Concern about the recruitment and retention of direct care
workers in home and community settings prompted the request
for this evaluation. In March 2022, the Joint Legislative
Oversight Committee directed our office to evaluate how our
state can create “a sustainable direct care workforce.” The study
request described a dire situation in which an insufficient supply
of direct care workers resulted in bad outcomes, including strain
on families, unmet medical and personal care needs, declining
health, and relocation to institutional care. A copy of the study
request is in appendix A.
Who receives direct care?

Children with developmental disabilities
4,670 children with developmental disabilities received direct care services through Medicaid in
2021. More children received school-based services. These children had functional impairments
related to a diagnosis of cerebral palsy, epilepsy, autism, intellectual disability, or a similar
condition.
Adults with developmental disabilities
12,660 adults with developmental disabilities received home- and community-based direct care
services through Medicaid in 2021. These adults had a functional impairment related to a
diagnosis of cerebral palsy, epilepsy, autism, traumatic brain injury, intellectual disability, or a
similar condition.
Adults over 65 or who have a disability
9,780 adults who were over 65, blind, or qualified for disability benefits through the Social
Security Act received home- and community-based direct care services through Medicaid in
2021. As a result of their condition, they were assessed to need direct care to remain living at
home instead of in a skilled nursing facility.
An additional 6,000 adults with a disability received direct care services in a certified family home or
assisted living facility through Medicaid in 2021.
In total, more than 33,000 people receive direct care services and supports through Medicaid.
Medicaid is also the largest payer for direct care services and supports. To qualify for Medicaid, there
are individual or family income and asset limits. Depending on how individuals qualify for services and
their income, they may need to pay for a portion of their care out-of-pocket.
11
Evaluation approach
Because the direct care workforce is not simply defined, we made
the following decisions to align our study most closely with the
concerns raised in the study request:
We focused on workers who provide face-to-face services,
including
help with activities of daily living such as eating,
bathing, and dressing;
help with instrumental activities of daily living
such as preparing meals, housekeeping, and
using the telephone;
teaching skills that support independent living;
and
unlicensed nursing care, such as monitoring
health status, wound care, and medication
management.
We focused on home and community settings. Some data
sources were not structured in a way that let us filter out
care by setting. When possible, we excluded direct care
provided in
nursing facilities,
hospitals,
physician’s offices,
outpatient care centers, and
intermediate care facilities.
We excluded direct care workers in K–12 schools. In the
public school system, these employees are classified and
generally fall under the title of “paraprofessional.”
Paraprofessionals provide various services, including
personal care and educational support. Our 2022 report,
K–12 Classified Employees, discusses the challenges
schools face in recruiting and retaining paraprofessionals
and other classified employees.
We focused on long-term services funded by Medicaid since
it is the largest payer of direct care. A small share of
direct care is funded by state and federal programs that
work exclusively with veterans and older adults who do
12
not qualify for Medicaid. In addition, some short-term

services (100 days or less) are covered by Medicare or by
private health insurance. We involved stakeholders
working with all payment sources throughout the
evaluation and incorporated relevant data when possible.
We used a mixed methods approach to answer the following
questions:
Is there a gap between the supply and demand of direct
care workers?
If there is a gap, why?
How can Idaho better support the direct care workforce?
We used data from multiple, independent sources to compare the

results and improve the validity and reliability of our findings. A
more detailed scope and list of research questions are in appendix
B. An explanation of our methods is in appendix C.
Report roadmap
The first step in understanding and addressing the challenges
facing the direct care workforce is to measure whether there is a Our first step was
shortage of workers. Chapter two reports our findings based on to determine
our analysis of U.S. Bureau of Labor Statistics and Idaho whether the
Department of Labor data to measure trends in the supply and described
demand of direct care workers in Idaho. Working with economic shortage existed.
consultants from Recon Insight Group, we estimated how many
more direct care workers the state would need to match national
employment levels.
Chapter three explains why the shortage exists according to the

direct care workers we surveyed, interviews we conducted, and
other research reports we reviewed.
Chapter four explains the shortage’s broader effects on Idahoans,

including businesses that provide direct care and people who rely
on services.
Chapter five explains why the shortage is a policy concern and

describes the impact that Medicaid has on the direct care
workforce.
Finally, in chapter six, we present our recommendations to help

create a more sustainable direct care workforce.
13
2 Is there a shortage of
direct care workers?
The United States had almost 5 million direct care jobs in 2021,
making it the country’s largest occupation.3 Over the next decade,
about 12 percent of projected, national job growth will be in
direct care.4 Researchers have attributed the increased demand
for paid care to an aging population, changes in the availability of
unpaid care, and an increased desire to receive care at home or in
the community. The U.S. Bureau of Labor Statistics projects that
the country will need to fill an additional 987,000 direct care jobs
over the next decade to meet the growing demand and replace
workers who leave the occupation.5
The supply of direct care workers has been described as a crisis.

Medicaid officials in 49 states reported experiencing a scarcity of
direct care workers.6 The problem is particularly acute in Idaho.
3. Bureau of Labor Statistics, Employment by Detailed

Occupation: 2021 and Projected 2031, https://www.bls.gov/emp/
tables.htm (last modified Sept. 8, 2022). Direct service professionals are
generally grouped into two occupation categories by the BLS: home
health and personal care aides (31-1120) and nursing assistants (31-
1131). The total number of workers in these two categories in 2021 was
4.98 million. The next largest occupation was fast food and counter
workers with 3.2 million.
4. Bureau of Labor Statistics, Supra note 1.
5. Bureau of Labor Statistics, Supra note 1.
6.Molly O’Malley Watts, Alice Burns, & Meghana Ammula,
Ongoing Impacts of the Pandemic on Medicaid Home & Community
-Based Services (HCBS) Programs: Findings from a 50 State
Survey, Kaiser Family Foundation (Nov. 28, 2022) https://
www.kff.org/medicaid/issue-brief/ongoing-impacts-of-the-pandemic-
on-medicaid-home-community-based-services-hcbs-programs-findings
-from-a-50-state-survey/ (last visited Dec. 21, 2022). All reporting
states (49) reported workforce shortages. One state, Virginia, did not
respond to this survey question.
14
Idaho does not have enough direct care

workers.
Idaho had about 23,000 direct care jobs in home, community,
and institutional settings in 2022. We found that our state would National staffing
need to fill 3,000 more direct care jobs to be comparable to levels reflect a
national staffing levels, as shown in exhibit 3. For the purposes of shortage of
our analysis, staffing levels are a composite measure of the gap
between supply of direct care jobs and demand.7 direct care
workers, and
Idaho had more direct care workers than national levels in the Idaho’s staffing
early 2000s but began falling behind in 2006. If demographic
and workforce trends continue, we estimate that by 2032 Idaho
is below the
will need more than 9,500 new direct care jobs to reach national national average.
levels. National comparisons provide a useful but conservative
estimate because a shortage of direct care workers has been
documented across the country.
Exhibit 3
The shortage of direct care workers compared with
national staffing levels is expected to triple by 2032.
Difference between the number of direct care workers in Idaho and
the expected number applying national staffing levels.
+2,500
National staffing levels
0
Idaho’s shortage
-2,500 compared with
-3,000 national levels
-5,000
-7,500
-10,000 -9,500
2002 2012 2022 2032
Source: Recon Insight Group analysis using data from Lightcast, U.S. Bureau of
Labor Statistics, U.S. Census Bureau, and Idaho Department of Health and
Welfare.
7. We worked with a regional economic consultant, Recon Insight

Group, to develop the statewide estimates of the direct care jobs gap.
We used the number of older adults and people with disabilities to
control for demand. More information about our analysis can be found
in appendix C.
15
The shortage is worse for certain regions
and services.
North Idaho and counties along the Washington and Oregon
border experienced the largest shortage of direct care workers.
Exhibit 4 shows that Region 4, which includes Ada County, was
the only part of the state with a higher supply of direct care
workers than the national levels. If this region were excluded, the
state would need more than 4,600 direct care jobs. Region 4’s
surplus to national staffing levels is expected to shrink by 80
percent over the next decade. At the same time, the shortage of
workers is expected to grow in every other region absent any
policy changes.
Exhibit 4
North Idaho had the largest staffing shortage and
every region is expected to see conditions worsen
over the next decade.
Difference between the number of direct care workers by region and
the expected number, applying national staffing levels.
Region 2022 2032
1 -2,900 -5,000 1
2 -140 -800
3 -1,120 -2,500 2
4 +1,680 +330
5 -100 -430
7
4
6 -310 -710
7 -40 -410
5 6
3
Source: Recon Insight Group analysis using data from Lightcast, U.S. Bureau of
Labor Statistics, U.S. Census Bureau, and Idaho Department of Health and
Welfare.
16
Another way to assess the workforce gap is to examine the

number of jobs by industry or common type of business. Idaho
was under-concentrated in two out of three main industries that
employ direct care workers compared to national levels. These
industries include services provided in homes, communities, and
institutions. As shown in exhibit 5, the largest under-
concentration of workers was in the industry called “services for
the elderly and persons with disabilities.” This industry includes
adult day care centers, non-medical home care, homemaker
services, group support, and companion care. Services within the
industry are often paid for by Medicaid, which we discuss further
in chapter 5. The other industries have more diverse funding
sources.
Exhibit 5
Idaho had a low concentration of workers in
industries with a higher share of services paid by
Medicaid.
Direct care workers by industry in Idaho and the state’s industrial
specialization relative to national levels.
Industry 2022 Direct Idaho’s concentration of workers
care jobs in in industry compared to national
industry average
Home health care 8,843 8% higher concentration

services
Nursing and residential 7,858 11% lower concentration

care services
Services for the elderly 6,097 45% lower concentration

and persons with
disabilities
Notes: Although our evaluation focuses on direct care in people’s homes and
communities, we also included all institutional settings in this table because
industry classifications do not separate intermediate care facilities from other
residential care.
Source: Office of Performance Evaluations' and Recon Insight Group analysis of

and data from Lightcast and the U.S. Bureau of Labor Statistics.
17
More recent data showed a sudden
decrease in workers.
Several people we interviewed reported that recently rising wages
in other sectors had attracted direct care workers to jobs in
restaurants, retail, and elsewhere. Our estimate of the worker
shortage relied in part on U.S. Bureau of Labor Statistics data.
This information is reliable in the long run but is not sensitive to
sudden changes because it pools data for three years.
To learn more about sudden shifts in direct care employment, we

worked with the Idaho Department of Labor to access more
frequently collected data. Most employers must report their
employees’ quarterly wage records to the department as part of
filing for unemployment insurance taxes. We analyzed quarterly
wage records from January 2012 through July 2022 for nonprofit
and for-profit businesses that received payment from Medicaid
for direct care services (see exhibit 6).
Exhibit 6
The number of employees working for direct care
businesses that rely on Medicaid fell sharply in
2021.
Cumulative change in the number of employees of direct care
businesses that rely on Medicaid in Idaho since 2012.
5,000 2,600
decrease in
direct care
4,000 workers
3,000 First COVID-

19 case in
Idaho
2,000
Stay-at-home order
1,000 lifted
0
2012 2014 2016 2018 2020 2022
Source: Office of Performance Evaluations' analysis of data from the Division of

Medicaid and Idaho Department of Labor.
18
We found that the number of workers employed had been slowly

growing until the trend was sharply disrupted in the second half
of 2021, when there were 2,642 fewer employees than the peak in
2020.8 We ran several calculations to see if there was a
connection between the timing of the drop in employees and
changes in the labor market wages or changes in the demand for
direct care. The analysis was inconclusive. We can say that if the
drop in employees was connected to people refusing services out
of concern about COVID-19, we would have expected to see the
change in the second half of 2020 and not a year later.
8. To target our analysis, we focused on employers that received

Medicaid payments that were larger than 50 percent of the total
reported salaries. For more information about the importance of
Medicaid in direct care, see chapter 5.
19
3 What is causing the
shortage?
In early 2021, the Center on Disabilities and Human
Development at the University of Idaho surveyed direct care
workers to learn more about the workforce. The center found
that low pay, limited benefits, and staff turnover contributed to
workforce challenges. Although the researchers raised concerns
about the generalizability of their survey due to its small sample
size, their conclusions were supported by results from national
reports and other state evaluations.9
We conducted an independent survey of direct care workers in

September 2022 and received 782 responses. For many workers,
low pay and other issues overshadowed the benefits of
emotionally fulfilling work.
9. The center’s survey received 238 responses.
20
The desire to help other people was not

enough to offset low pay and other
workplace challenges.
Through our survey, we found that workers were often attracted
to direct care because they wanted to help other people.
According to workers, direct care is rewarding but emotionally
and physically taxing. Many employers did not offer benefits.
Some workers were also dissatisfied with limited training and
career advancement.
But ultimately, insufficient pay was the biggest factor that led
Ultimately,
direct care workers to leave the occupation. Workers had the insufficient pay
knowledge, skills, and ability to earn more outside of direct care. was the biggest
The resulting high turnover intensified challenging work factor that led
conditions for those who remained. direct care
workers to leave.
Types of direct care work

Direct care workers have many different responsibilities. We asked workers to indicate which of the
following best described their job:
Direct support professional or community support worker services, such as coaching or skill-
building for people with intellectual or developmental disabilities to live more independently
in any setting
Personal care services, such as help with eating, bathing, homemaking, and other activities
essential to health and comfort in any setting
Home health services, such as basic wound care, monitoring of health status, and other
healthcare services provided in the home
Nursing assistant services, such as basic wound care, monitoring of health status, and other
healthcare services provided outside a home setting
Some of our survey questions were only applicable to certain workers. When workers were not asked
a question, we noted so in exhibits throughout the chapter. For more information, see appendix C.
21
Rewarding but challenging work
Workers had several reasons for entering direct care. Many
started providing direct care to support a friend or relative or
because they liked helping people, as shown in exhibit 7. In a
separate question that asked what they liked most about their job,
69 percent of workers said that it was the person they supported.
Exhibit 7
Many direct care workers decided to become paid
caregivers because they like helping people.
Direct care worker response to the survey question: Why did you
decide to become a paid caregiver?
8% I want to become a nurse or other

health care professional
11% There were paid caregiver jobs available
My friend or family member was also a paid

12%
caregiver
14% The work hours fit my schedule
21% Other
39% I cared for a friend or relative
43% I like helping people
Source: Office of Performance Evaluations' analysis of survey data.
However, direct care work is also challenging and carries some

Direct care risk. According to the U.S. Department of Labor, direct care
workers have a workers have a higher than average workplace injury rate and
higher workplace experience more injuries than many occupations known to be
high risk, such as firefighting and construction work.
injury rate than
construction While many of the workers who responded to our survey
workers. reported low risk of physical injury at work, more than half
reported that it was not uncommon for them to feel unsafe due to
exhaustion and burnout (see exhibit 8).
22
Exhibit 8
Direct care workers report a high risk of exhaustion
and burnout, and some feel unsafe due to a risk of
physical injury and verbal abuse.
Direct care worker response to the survey question: How often do you
feel unsafe at your job for the following reasons?
Often or Sometimes Rarely Very rarely
always or never
Exhaustion and burnout 27% 39% 14% 20%
Verbal abuse 8% 19% 20% 52%
Physical injury from

job responsibilities
(e.g. lifting, transferring ) 6% 20% 24% 49%
Physical injury from client 4% 18% 22% 56%
The risk that workers experience depends on the job they do and
the needs of the people they serve. Direct support professionals
and nursing assistants most frequently reported verbal
abuse. Direct support professionals also most frequently reported
a risk of physical injury from the people they support. Home
health aides most frequently reported feeling unsafe due to a risk
of physical injury from their job responsibilities, such as lifting or
transferring people. Although many direct care workers often feel
safe at their jobs, challenging work conditions can take a toll
when they occur.
“
I was getting death threats and being called [names]
constantly. Supervisors and management didn't seem
willing to do anything, they didn't offer appropriate
training for staff for de-escalation or anything. It was
exhausting. As soon as I could, I got out.
- Direct care worker who responded to our survey
23
Limited training and advancement for some workers
People with disabilities, families, and advocates reported
concerns about training and career advancement for workers. We
found support for these concerns in parts of the direct care
industry. About 35 percent of workers who responded to our
survey were dissatisfied with opportunities for career
advancement. About 18 percent reported that their training did
not prepare them well for their job. When we asked direct care
workers about training among their peers, 57 percent reported
that most direct care workers in Idaho have too little training.
Limited training and career advancement was a larger concern

for direct care workers who
were not certified nursing assistants;
worked in homes rather than more institutional and
medical settings such as nursing facilities,
hospitals, and doctor’s offices; and
cared for children and adults with intellectual and
developmental disabilities.
Results of our survey and research from other states indicate that
improving training will likely only help recruitment and retention
issues if coupled with higher pay.
Compensation not competitive

Direct care workers often did not have access to paid leave or
benefits through their employers, but low wages were their
primary concern.
Paid leave
Almost 6 in 10 workers reported that their employer did not offer
8 in 10 paid personal or vacation days. Almost 8 in 10 direct care
workers reported that their employer did not offer paid sick
direct care leave. Lack of paid sick leave is of particular interest because
workers reported workers may not be able to afford to miss work given their low
that their wages. This may lead workers to come in when they are sick,
employer did not putting people who receive services with medical conditions at
offer paid sick risk.
leave.
24
Benefits
More than 7 in 10 direct care workers reported that their
employer did not offer a retirement plan. More than half of
workers reported that their employer did not offer health
insurance to any direct care workers. More than 6 in 10 reported
that they did not qualify for health insurance even if it was
offered.
Government-sponsored insurance plans were predominantly

used by direct care workers who responded to our survey, see
exhibit 9. About 18 percent of direct care workers had health
coverage through Medicaid, likely due to the recent expansion of
Medicaid to adults with low incomes. National research suggests
that 45 percent of direct care workers rely on public assistance,
such as Medicaid or food assistance.
Exhibit 9
If they had health insurance, direct care workers
generally got it through a government program or
family member’s job.
Direct care worker response to survey questions about their
participation in health insurance.
17% No health insurance

1% Veteran’s Affairs
2% Other
3% A different job
4% Private pay outside the healthcare marketplace
8% The healthcare marketplace
15% Medicare
16% My direct care job
18% Medicaid
Someone else’s job, such
22%
as a spouse or parents
25
Wages
Workers who responded to our survey received a wage of $14 per
hour on average.10 Although many direct care workers wanted
benefits, our survey indicated that higher pay was more
important. More than 75 percent of direct care workers who were
actively looking for a new job said that higher pay was the main
thing that would stop them from leaving as shown in exhibit 9.
On average, workers said that $19 per hour would stop them
from leaving their jobs at the time of our survey.
Exhibit 9
About three quarters of direct care workers reported
that higher pay was the main thing that would
prevent them from leaving their job.
Direct care worker response to survey question: What is the main thing
your employer could do to change your mind about leaving your job?
Nothing would
make me stay, 3%
Other, 9%
Higher pay, 76%
Better
benefits, 7%
Different job
tasks, 3%
Different
supervisor or
manager, 2%
Note: Certified family homes were not asked this question.
10. This calculation excludes certified family homes, who are usually
family members. Certified family homes receive a Medicaid payment
that is less than minimum wage.
26
Nursing assistants in Idaho were paid $14.16 per hour on

average, while other direct care workers were paid $11.49 per Direct care
hour, according to the U.S. Bureau of Labor Statistics. Direct care workers could
workers had higher wage alternatives to direct care in 2020. We have received a
worked with economists to identify comparable jobs outside 36-39 percent
direct care for which workers would be qualified. The typical pay increase by
nursing assistant could have received $19.64 by leaving direct
leaving the
care, and other direct care workers could have received $15.68
industry.
These alternative wages had an annual opportunity cost of
$11,398 for nursing assistants and $8,715 for other direct care
workers who chose to remain in the industry.11 About 23 percent
of direct care workers who responded to our survey reported that
they would likely leave their job within the next year.
“
Pay is capped at below the average for a fast-food
worker. I am changing ostomy bags, cathing, and
doing advanced care. I have no opportunity to increase
my pay even when the cost of living goes up. I have no
sick days. I don't have insurance. I don't make enough
to get off Medicaid even working full time.
– Direct care worker who responded to our survey
High turnover makes work harder

High turnover made the job of those who remained in direct care
harder. In August 2022, Idaho’s total job opening rate was 7.1
percent as reported by the U.S. Bureau of Labor Statistics. During
the same month, the job opening rate for direct care businesses
participating in our survey was 20 percent. When we asked direct
care workers how insufficient staffing affects their job, they
described the following:
managers had to step in to help
unpredictable schedules
too much work
rushed work
long hours
few breaks
little or no time off
11. These calculations were for full-time work.
27
Workers said these conditions led them to experience stress,
guilt, poor mental health, exhaustion, and burnout.
“
It really affects the clients by not having enough staff.
They are falling more often, [have] increased depression
which has led to decreased mobility and less quality of
life. The crisis is terrible right now. It scares me to think
of how many seniors are dying alone in their homes and
possibly not found for days or longer.
Many of my coworkers are working overtime every week
“ by at least 2 shifts (16 hours). … Because of this, many of

us cannot take any time off to care for ourselves, our
families, or for other personal reasons because there is no
one to cover our shifts. Everyone is working as much as
they can.
Our more observant clients are acutely aware of the staff

shortage, and turnover. It is harmful to their sense of self,
their sense of safety, and their sense of belongin[g] when
it appears no one wants to work with them. Our job can
already be challenging for many reasons; not everyone is
capable of doing it. Staffing shortages cause an already
challenging profession to become that much more
challenging for both the staff and the clients.
28
How does the shortage

affect Idahoans? 4
The direct care workforce shortage affects the 33,000 Idahoans
who rely on services and supports through Medicaid, their
families and communities, and more than 750 businesses that
offer these services and supports. The shortage limits the ability
of businesses to implement the most effective business model
and people to choose the model of care that is best for them.
A recent survey of 718 direct care businesses across the country

found a series of negative consequences stemming from not
having enough workers:
83 percent of respondents turned away people seeking
services
63 percent discontinued services
55 percent considered additional service cuts
92 percent struggled to achieve quality standards12
People who rely on services and supports must find a balance of

paid and unpaid care that works best for them. Insufficient
staffing disrupts this balance. As businesses make difficult
choices, people who need direct care are served by less qualified
workers, spend more time on waitlists, are turned away, or
receive less than their approved level of care. Family members
and other unpaid caregivers often act as the backup plan, which
risks their ability to earn a living. Not everyone has family
available to step in on short notice and people may go without
needed care.
12. American Network of Community Options and Resources

(ANCOR), The State of America's Direct Support Workforce Crisis
2022, Alexandria, VA: ANCOR, 2022, 2
29
Businesses that provide direct care have
limited choices.
We surveyed the network of nonprofit and for-profit businesses
that provide direct care in Idaho. Of the 142 businesses that
responded, 86 percent reported they do not have sufficient
personnel to meet the demand for services. Most businesses
reported that recruitment and retention of direct care workers
was very challenging (see exhibit 10).
For businesses mostly funded by Medicaid, the effects of the

For businesses shortage were worse. Those businesses were half as likely to say
mostly funded by that they had sufficient personnel when compared with
Medicaid, the businesses that received most of their revenue from other
effects of the sources, such as Medicare or private pay. Job opening rates were
shortage were also higher among businesses that relied mostly on Medicaid.
worse. Businesses reported that payments from Medicaid were
insufficient to cover the cost of providing quality care. In
response, they reported facing poor choices like hiring employees
they would not normally hire, providing less care than needed,
and providing lower quality care.
Exhibit 10
Businesses reported that recruitment and retention
of direct care workers was challenging.
Direct care business response to the survey question: How challenging
is recruitment and retention of direct care workers?
2%
Recruitment 9% 89%
4%
Retention 30% 66%
Easy Somewhat challenging Very challenging

30
Having less qualified employees

Since low wages make direct care businesses less competitive in
the labor market, they have fewer options when hiring and are
more likely to keep an employee who is not a good fit. As shown
in exhibit 11, more than 8 in 10 businesses reported hiring
employees with fewer qualifications and keeping poor-
performing employees longer than they would like. People who
receive services and independently hire employees reported
similar experiences.
Exhibit 11
Direct care businesses changed their practices
because of recruitment and retention issues.
Direct care business response to the survey question: Since January
2022, has your organization had to make any of the following
accommodations because of recruitment and retention challenges?
83% Kept low performing employees longer
83% Hired employees with fewer qualifications
80% Declined to accept new clients, all needs
72% Had a wait list for services
65% Declined to accept new clients, high needs
46% Provided less than the client’s approved level of care
43% Declined to accept new clients, low needs
40% Reduced the number of Medicaid clients
19% Decreased paid training opportunities for staff
16% Other
4% None of these
31
The importance of a good worker
We asked people who received services (primarily adults with developmental disabilities) two
questions: 1) What makes a good direct care worker? and 2) What makes a bad worker?
The responses showed that people most valued being treated with basic human dignity. Responses
included the following answers:
“they show up consistently”
“are a good communicator”
“not lazy”
“compassionate and friendly”
“has learned about me”
While descriptions of bad workers included concerns about attitude and work ethic, most
concerning were the frequent experiences with workers whose behavior was abusive, neglectful, or
exploitative. Responses included the following answers:
“just plays on their phone”
“ignores me”
“tries anything sexual since we have a hard time saying no”
“walks out on me”
“steals stuff”
We recommended a caregiver misconduct registry in our 2019 report, Southwest Idaho Treatment
Center, and our 2020 report, State’s Response to Alzheimer’s Disease and Related Dementias.
Stakeholders and agency officials produced a 2019 whitepaper outlining several paths the state
could take to create a registry. However, the Legislature must determine which agency is
responsible to develop and implement a registry.
As of the release of this report, Idaho still does not have a caregiver misconduct registry. The Idaho
Council on Developmental Disabilities has been working with Boise State University to study
ongoing issues with maltreatment of adults with disabilities.
Limiting access to services and supports

Less than 1 in 3
When businesses do not have sufficient staff, they often limit
surveyed their services. The Division of Medicaid does not have effective
businesses knew measures to determine whether people who need services can
that there was a access them. The division tracks provider closures and monitors
way to report complaints. When we surveyed businesses, we found that less
access issues. than a third knew that there was a way to report when insufficient
staffing affects their ability to provide care.
32
Our interviews for this evaluation indicated that people may

hesitate to file a complaint out of fear that the business or
workers will be blamed for systemic staffing issues. Because of an
overreliance on self-reported data, the division has inadequate
information about access to services and supports.
Our survey revealed that businesses used waitlists, turned away

clients, and provided less than the approved level of care.
“
I have clients that have wanted a new worker for years
and have gone to multiple agencies only to find that no
workers are available. Currently 13 of my 27 clients have
hours available that cannot be filled by workers and are
thus not receiving services and supports they should be.
– Fiscal intermediary who responded to our survey
Creating waitlists
Most state Medicaid programs have a waitlist for home- and
community-based services. Idaho does not have a formal waitlist
7 in 10 direct
for services. However, our survey found that about 7 in 10 direct care businesses
care businesses had waitlists. In essence, the state’s waitlist is that responded
pushed down to the level of local businesses. Medicaid enrolls all to our survey had
eligible people who apply for coverage, but people may struggle waitlists.
to find someone who can give them appropriate services and
support. The state does not track the extent to which people
access their approved services, nor does the state track the reason
people do not receive services.
Businesses that receive most of their revenue from Medicaid, like

developmental disability agencies and personal care agencies,
were almost twice as likely to report having a wait list compared
to businesses that receive most of their revenue from other
sources. These agencies are the primary providers of services that
help older adults and people with disabilities live in their own
homes rather than supported residential settings or institutions.
8 in 10
Turning away people seeking services responding
Among the businesses that responded to our survey, 80 percent businesses
reported that they turned away people seeking services because turned away
of staffing challenges. About 40 percent specifically served fewer people seeking
people who relied on Medicaid. Businesses that rely solely on services because
Medicaid reported trying to reduce unbillable travel time by
of staffing
declining people who needed fewer hours of support or who lived
in remote areas. Businesses also reported declining people whose
challenges.
33
support needs were complex because the business would need
workers with training to serve people with specialized needs.
People with complex needs are also more likely to need a lower
staff ratio, like one worker to one person, than those with lower
assessed needs.
Providing less than the approved level of care

Businesses may also continue serving people with disabilities but
provide them with less support. Medicaid requires medical and
functional assessments to determine whether direct care is
necessary and the amount needed for each person. We heard
several reports of people receiving less than their approved level
of support. For example, a medical professional may assess and
determine that a person needs 30 hours of personal care and
other supports each week, but a business will only provide 20. In
response to staffing issues, 46 percent of businesses reported that
they provided less than the approved level of support for the
people they serve.
To learn more, we analyzed data provided by the Division of

Medicaid’s Bureau of Long Term Care.13 Our analysis confirmed
survey and interview findings that the problem was getting
worse. Over time, the amount of support people received
decreased compared to their assessed level of need.
Prior rate We also found that a 15 percent Medicaid rate increase in 2018
adjustments resulted in people receiving an average of 10 more hours of
increased the support each month, indicating that the rate increase allowed
businesses to hire more workers and provide more support. A
amount of care
smaller 5 percent rate increase at the start of the pandemic may
people received. also have helped retain workers.
13. The Bureau of Long Term Care conducts assessments for state plan
personal care services and the aged and disabled waiver. We were unable to
receive sufficient data from the Bureau of Developmental Disabilities for this
analysis.
34
People who rely on services, and their

families, have limited choices.
The direct care staffing crisis leaves people with limited choices in
the type and quality of services they receive. Choices look
different for each person depending on their needs and
circumstances.
People who would like a different direct care worker may
settle for lower quality of services and supports
because they are unable to find a replacement.
Family caregivers may feel forced to work outside the
home and hire a direct care worker.
People who prefer to directly hire and manage their
workers may feel forced to go through a private
business because high turnover makes it too risky
not to have a family member who can afford to
step in with short notice.
People with higher needs who prefer to live at home may
be unable to find a provider, making them feel
forced into more expensive institutional settings.
Stress for families

Family members and other unpaid caregivers often step in to help
when a worker does not show up for a shift or similar staffing
challenges occur. Our survey and interviews indicated that
staffing challenges often affect the ability of family members to
earn a living (see exhibit 12).
35
Exhibit 12
Staffing issues affected the ability of family
members to earn a living outside the home.
Family caregiver response to the survey question: As a result of
caregiving, did you ever experience any of these work-related
activities?
54% Went in late, left early, or took time off
33% Reduced work hours or took a less demanding job
29% Gave up working entirely
23% None of these
22% Took a leave of absence
15% Lost job benefits
13% Turned down a promotion
9% Received a warning about performance
5% Retired early
Some families find that it is best to keep care in the family and
avoid hiring workers, so they structure their lives to do so.
Qualified people who live with an adult with disabilities can
enroll as a Medicaid provider by going through the process of
becoming a certified family home. Certified family home
providers act as a critical safety valve for direct care demand in
Idaho by covering some costs of families caring for their loved
ones.
However, they are also subject to the systemic challenges in

Medicaid’s rate-adjustment process that we identified in our
2022 report, Medicaid Rate Setting. The reimbursement rate for
certified family homes was last updated in 2008. As a result,
many certified family home providers earn less than they would
working full time at a minimum wage job outside the home,
creating an opportunity cost for families who pursue this option.
36
Risks to people who rely on services

People who rely on direct care services do not always have family
or other unpaid supports immediately available to help when
there are staffing issues, which can create troubling and People who rely
sometimes dangerous situations. People may feel forced to keep on direct care
workers who do not show up when they are scheduled, provide reported settling
poor quality care, or cause other issues. Just over 83 percent of for poor-
survey respondents who rely on direct care workers reported that
performing
it would be very challenging to replace their worker. Among
them, 56 percent said that this led them to keep workers longer
workers because
than they would like. of the staffing
crisis.
Workers reported that insufficient staffing resulted in negative
experiences for people who rely on direct care including the
following examples:
fewer activities and less time in the community

distracted or inattentive care
an insufficient amount of care
late or missed care
increased sadness and depression
more stress and behavioral symptoms
injuries
37
Why is the shortage a
5 state policy concern?
Idaho’s Medicaid rates and rate-setting process are major drivers
of the direct care worker shortage. Many businesses rely on
Medicaid as their primary funding source for two reasons: 1)
private health insurance does not cover long-term services, and
2) many people who pay out-of-pocket eventually exhaust their
resources until they qualify for Medicaid.
Medicaid’s rate-setting process has deficiencies that leave

businesses in a position where they cannot attract enough
workers to meet demand and replace people leaving the
occupation. Restricted business choices lead to restricted choices
for Idahoans who rely on direct care supports. This becomes a
policy issue because the state relies on choice to achieve its goal of
ensuring access to quality care that is efficient and economical.
38
Medicaid is the primary payer of direct

care services.
Medicaid is the largest payer of long-term care nationwide, as
shown in exhibit 13. Compared with other long-term care
services, Medicaid pays for a larger share of personal care and
services for people with intellectual and developmental
disabilities. For example, personal care agencies in Idaho
reported that 77 percent of their expenses would be paid through
Medicaid in the 2017 cost survey conducted by the Division of
Medicaid. The University of Kansas Center for Developmental
Disabilities estimated that Medicaid paid for 98 percent of
services to people with intellectual and developmental disabilities
in Idaho in fiscal year 2019.14
Exhibit 13
Medicaid was the largest payer of long-term care
in 2020.
Nationwide spending on long-term care by funding source in 2020.
Private
insurance, 8%
Medicaid, Veterans Health, Out of

53% Indian Health pocket,
Services, and 13%
other sources,
26%
Source: Kaiser Family Foundation analysis of 2020 National Health Expenditure

Accounts.
Private insurance
and Medicare
cover short stays
Medicaid is the primary payer of direct care for three reasons. in nursing homes
First, private insurance plans and Medicare typically do not cover
but not services
long-term, direct care services though they may cover hospice or
short-term supports needed because of an acute medical
provided at home
condition. or in the
community.
14. University of Kansas Center for Developmental Disabilities,

State Profiles for Spending During Fiscal Years 1977—2019, (last
visited Dec. 27, 2022 https://stateofthestates.org/state-profiles/).
39
Second, private long-term care insurance policies exist, but few
people purchase coverage, and the number of insurance
providers that offer policies has decreased over the last two
decades. These insurance policies are generally cost prohibitive
and purchased by individuals rather than being sponsored by
their employers. In 2021, only 1.4 percent of Idahoans had long-
term care insurance according to the Idaho Department of
Insurance 2021 Health Survey.
Finally, many people begin paying for long-term care out of

pocket but eventually spend through their assets. Medicaid then
becomes the remaining funding option.
40
Idaho has designed its long-term care

programs to embody personal choice,
self-determination, and dignity.
States have long supported people with disabilities and older
adults who would otherwise not have care. A 1948 case from the
Supreme Court of Idaho notes that “the granting of aid to its
needy aged is a well-recognized obligation of the state and is a
governmental function tending to promote the public welfare.”15
After Congress created Medicaid in 1965, Idaho organized many
of its long-term care programs under the administration of
Medicaid.
In the first half of the twentieth century, states usually provided

long-term care in institutions. Medicaid initially kept this model
of care by paying for state-run or private nursing and
intermediate care facilities. In 1981, Medicaid changed its model
by providing in-home, direct care services for eligible Idahoans,
particularly for adults over 65 and people with physical,
intellectual, or developmental disabilities. The state’s current
Medicaid plan emphasizes the values of personal choice,
independence, self-determination, privacy, and dignity.16 These
values are reflected by providing people with the option to receive
services in their homes or community.
Since caring for someone in an institution is expensive, providing

home- and community-based services aligns with the state’s goal
of being fiscally responsible. In 1981, 61 percent of Idaho’s total
Home- and
Medicaid expenses were for long-term care in an institutional community-
setting. As people began to use home- and community-based based services
services more than institutions, long-term care took up a smaller are less
share of the state’s Medicaid budget. By 2019, long-term care expensive than
made up just 38 percent of overall Medicaid spending, as shown institutional
in exhibit 14.
care.
15. State ex rel. Nielson v. Lindstrom, 68 Idaho 226 (1948).

16. Idaho Code §§ 39-5601, 56-251(2)(a)-(b), 56-255
41
Exhibit 14
As Idaho relied more on home- and community-
based services than institutions, long-term care was
a smaller share of the Medicaid budget.
Institutional care versus home- and community-based services as a
share of Idaho’s Medicaid budget over time.
100%
75%
50%
25%
0%
1985 1990 1995 2000 2005 2010 2015
Institutional Home- and community- Other
care based care Medicaid
Source: Office of Performance Evaluations' analysis of data from U.S. Department
of Health and Human Services.
The shift to more home- and community-based services

decentralized long-term care and led the state to rely more on
consumer choice to ensure quality. When most people who
needed services were in an institution, the state’s ability to
achieve its policy goals was largely up to state employees because
the institutions were run by the state. Institutions are still
subject to strict federal standards.
Now, most people who need direct care are expected to find a
private business that meets their needs or hire a care provider
directly. For this model to work, payment rates must be
sufficient to create meaningful choices. Instead, we found
workers often feel they have no choice but to leave direct
care because of low wages;
businesses often feel they must settle for applicants with
fewer qualifications and keep poor-performing
workers longer than they would like; and
people who need services often feel that they must settle
for lower quality of services or care provided in an
institution, when they would rather be at home or
in their community.
42
The rates and rate-setting process were

major drivers of the worker shortage.
Idaho’s Medicaid rates do not support a competitive wage for
most direct care services. Administrative rule lays out the general
framework of rate development, using a target wage with
adjustments for overhead costs, including employee-related
expenses, program-related expenses, and general and
administrative costs.
By rule, rates are set every five years with some possibility to be
updated if the division determines it is necessary. However, as
soon as a target wage is set into the Medicaid rate, it ages and is
less likely to reflect competitive pay as intended. To see this
effect, we sampled a set of direct care service rates. We
referenced the wage targets from the most recent cost surveys
and compared the wages supported by the rates to the wage
targets from 2017 through 2022. The hourly target wages and
supported wages are reported in exhibit 15.
We found that hourly wages supported by rates were often closer

to target wages after a cost survey, but tended to drift away over
time. Exhibit 16 shows the variance between the hourly wages
supported by the rates compared to target wages.
Four components of Medicaid rates

The division typically sets rates for direct care based on a target wage for workers plus a percentage
of overhead. The rate has four components:
1) target hourly wage for direct care workers
2) employee-related expenses, such as benefits, typically as a percentage of the target

hourly wage
3) 3) program-related expenses indirectly related to care, such as wages and benefits for
professionals who oversee direct care, typically as a percentage of the target hourly wage
4) general and administrative costs, related to the operating of the business but not related
to client care, typically as a percentage of the target hourly wage.
43
Exhibit 15
The Division of Medicaid uses different sources to set target
wages for services.
Medicaid’s direct care target wages come from the U.S. Bureau of Labor Statistics
(BLS) or from surveys of nursing homes and intermediate care facilities (WAHR).
Services 2017 2018 2019 2020 2021 2022
Aged and Disabled and Associated State Plan Services
Attendant and personal care
Target wage: WAHR $11.50 $11.94 $12.65 $13.53 $14.32 $16.55
Supported wage $10.40 $11.85 $11.85 $12.51 $12.51 $13.93
Homemaker
Target wage: WAHR $10.39 $10.89 $11.06 $11.75 $12.37 $14.03
Supported wage $ 9.17 $10.71 $10.71 $11.35 $11.35 $12.20
Adult Developmental Disabilities Services
Adult day health
Target wage: BLS, recreation workers $13.90 $14.57 $13.49 $15.85 $15.13 $17.26
Supported wage $ 9.27 $ 9.27 $ 9.27 $ 9.27 $ 9.27 $17.23
Supportive living
Target wage: BLS, personal care aides* $10.68 $11.05 $13.89 $14.48 $14.86 $15.76
Supported wage $10.76 $10.91 $10.91 $10.91 $10.91 $16.19
Children’s Developmental Disabilities Services
Habilitative supports and crisis intervention technician
Target wage: BLS, recreation workers $13.90 $14.57 $13.49 $15.85 $15.13 $17.26
Supported wage $ 6.82 $ 7.20 $ 9.89 $ 9.89 $ 9.89 $ 9.89
Notes: This table comprises the following billing codes: H2011-HA, H2015, H2015-HA, H2015-TJ, H2016,
H2022, S5100, S5125, S5130, and T1019. Supported wages were calculated by taking the rate and
subtracting out the overhead costs as described in the relevant cost surveys. The overhead costs include the
portion of the rate intended to cover employee, program, general, and administrative expenses.
* In 2019, the BLS combined personal care aides with home health aides, which led to an increase in the
average target wage.
Source: Office of Performance Evaluations’ analysis of data from the Department of Health and Welfare, U.S.
Bureau of Labor Statistics, and Myers and Stauffer.
44
Exhibit 16
Hourly wages supported by Medicaid rates were closer to target
wages after a cost survey, but drifted over time.
Hourly difference between the Division of Medicaid’s target wages and wages actually
supported 2017
by their rates.
2018 2019 2020 2021 2022
Aged and Disabled and Associated State Plan Services
Attendant & -$0.09 Target wage

personal care
-$1.10 -$0.18
-$1.83
Homemaker
Cost
-$1.25
survey
-$2.62
2017 2018 2019 2020 2021 2022

2017 2018 2019 2020 2021 2022
Adult Developmental Disabilities Services
Supportive living +$0.42
+$0.08
Target wage
-$0.14 -$0.03
Adult day
health
-$4.63
-$5.86
2017
2017 2018
2018 2019
2019 2020
2020 2021
2021 2022
2022
Children’s Developmental Disability Services

Target wage
-$3.60
Habilitative supports &

crisis intervention
-$7.08
-$7.37
2017 2018 2019 2020 2021 2022
Source: Office of Performance Evaluations’ analysis of data from the Department of Health and
Welfare, U.S. Bureau of Labor Statistics, and Myers and Stauffer. 45
The division’s goal in setting wage targets is usually to ensure
that rates are sufficient to promote a viable business ecosystem.
However, both rules and practice are inconsistent between
provider types without an apparent policy purpose. In some
cases, rule prescribes the method or limit for a rate component.
In other cases, Medicaid has discretion. Some examples of
inconsistencies include:
For wage benchmarks, most services provided by

personal care service agencies have been set using wages
calculated from a survey of Idaho’s nursing homes and
intermediate care facilities. Services from developmental
disability or residential habilitation agencies have been
set based on occupation codes from the U.S. Bureau of
Labor Statistics.
For employee-related expenses, personal care service

agencies have rates set based on actual costs from the cost
survey while developmental disability services are set
using estimates from the U.S. Bureau of Labor Statistics
and Internal Revenue Service. This was over a 20-
percentage point difference in recent cost surveys (15.85
percent versus 36.86 percent).
Many developmental disability services have a 10-percent

cap on the amount of general and administrative costs
that can be included in rate development. Other services
do not have such a cap.
Certified family home providers often do not try to

operate as a small business since they are usually only
taking care of their families. Their rates are set differently
under each Medicaid program and have not been updated
in the developmental disability program since 2008.
46
The division’s limited management

capacity hampers access to care.
People who rely on direct care, their family members, and other
stakeholders frequently reported that Medicaid staff were
overwhelmed by their caseloads and that officials were often
unresponsive.
“
Everyone goes to work for the department for the right
reasons – they care about people. But you get to the
point where care gets overwhelmed with work. They've
got one person doing five people's jobs.
– Parent of an adult receiving services from the Bureau of
Developmental Disabilities
Our 2022 evaluation, Medicaid Rate Setting, found that the

division had limited capacity to effectively implement a rate-
review process. We further found that the division did not have
the information it needed to prioritize rates for review or to know
whether rate adjustments had their intended effect, especially on
access to care.
In this evaluation, we found that the division continues to

struggle to manage or prevent problems that affect the ability of
the state to achieve its policy goals. In addition to the findings
already discussed, we found that: 1) the division does not have a
strategy to address emergent issues with payment and benefit
design; 2) support brokers, who are not direct care workers but
are required to support people who access direct care through the
self-direct model, do not receive adequate support; and 3)
language access services are insufficient.
Payment and benefit design issues

Payment and benefit design choices affect which business
strategies are viable and thereby affect people's access to services.
For example, covering travel costs in the standard unit rate
creates a disadvantage for businesses whose workers travel more
than average. This disadvantage may mean that people whose
services require more travel per amount of billable time have less
access to care.
47
The division does not have a strategy to address emergent issues
related to payment and benefit design. The cost studies,
scheduled to occur every five years, represent the perfect
opportunity to address these issues such as the following
examples:
how should training costs be incorporated into the
program-related expenses component of the rate
or should they be billed or reimbursed separately
how should travel costs be incorporated into the program-
related expenses portion of the rate or should they
be billed or reimbursed separately
how should attendant care and homemaker services be
billed—separately or as a single service
should the same rates apply statewide or should there be
region-specific rates
For cost studies to effectively address these emergent issues, the

division must design the surveys to collect information relevant
to the issue and, if possible, pair the cost survey with data on
service access or quality. Changes to payment or benefit design
would also ideally include strategies to monitor effects on access,
quality, and spending.
Support for those on self-direction

Federal regulations require the state to offer information and
assistance to people using the self-directed model. Idaho fulfills
this responsibility for people with budget authority through the
use of support brokers.
Support brokers are employed by people on the self-directed

model, but their job would not exist without Medicaid. Our
survey found that although support brokers feel responsible for
Support brokers
Some people have authority over their budgets in the self-directed model. People may use those
funds to hire their own workers, modify their home, or pursue other things that help them live
independently. Support brokers help people create their spending plan, locate resources, develop a
back-up plan to handle situations when their worker does not come, and consider ways to terminate
workers who are not meeting the people’s objectives.
48
helping people on the self-directed model with many aspects of

Medicaid services, they often do not feel well prepared to do so.
Support brokers also have business costs, such as printing and

transportation, which are not tax deductible or paid for by
Medicaid. They also face complex tax issues as a result of their
role with Medicaid. Support brokers reported that despite
repeated requests, they have not received help from the division
to address these concerns.
Additionally, older adults and people with physical disabilities do

not have budget authority. They also do not have support brokers
to help understand service options and assistant in accessing
services. These services are particularly important for older
adults and other people who do not have family or other unpaid
supports available. The division eliminated case management in
response to cost cutting priorities around the 2008 recession.
Language interpretation
We heard several reports of difficulties with language access. One
example was the way the division provides language
interpretation through a phone help line. Sometimes instead of
using the language access line, children with developmental
disabilities who speak English were relied upon to interpret
conversations between their parents who did not speak English
and people managing their services and supports. As a result, the
children’s parents may not have the information necessary to
make decisions about care.
49
6 Recommendations
Reports in every state have documented the challenge of

recruiting and retaining enough direct care workers. As a result,
states have tried a host of strategies to alleviate the problem.
Some important lessons have emerged as states have wrestled

with implementing solutions. First, total compensation–pay,
benefits, number of hours worked, bonuses, and reimbursements
–matters. While better compensation alone may not be sufficient,
it is necessary to improve recruitment and retention.
Second, policymakers and stakeholders must choose strategies
that align with the state’s goals and values. No matter how much
potential a strategy has on paper, effectiveness will be
determined by the collective commitment to good
implementation.
Third, implementation requires a long-term collaborative effort
among the network of state leaders that affect direct care. In
Idaho, these agencies include the following:
Legislature
Governor’s Office
Department of Health and Welfare
Commission on Aging
Council on Developmental Disabilities
State Independent Living Council
Department of Education
Division of Veterans Services
Division of Vocational Rehabilitation
Division of Career Technical Education
The recommendations in this chapter are intended to address the

most immediate causes of the direct care shortage in Idaho.
50
Medicaid rates should support

competitive wages to achieve a
sustainable direct care workforce.
The most straightforward strategy the state can employ for a
sustainable workforce is to ensure that the rates support
competitive wages. The following four improvements to the rate-
setting process would help:
improve wage targets
communicate the cost of inflation to the Legislature and
adjust rates annually
incorporate regional rate adjusters
improve transparency
We recommend that the division form its wage

targets using multiple occupations.
As described in the last chapter, target hourly wages serve as the
foundation for Medicaid rates. Idaho rule prescribes two sources
for setting wage targets:
a survey of wages in Idaho skilled nursing and
intermediate care facilities17
mean hourly wages for Idaho reported by the U.S. Bureau
of Labor Statistics (BLS)
When BLS data informs the wage target, the division selects the
occupation profile that most closely aligns with the duties,
education level, and supervision requirements of the direct care
workers providing the service. The occupation profile is selected
with feedback from stakeholders.
17. The survey collects the weighted annual average hourly rate of pay
by employment type. The wage target for personal care services is a
weighted average of applicable employment types. IDAPA
16.03.10.307.03—04.
51
The division uses one occupation profile to set rates for most
services even though it can use one or more profiles to set the
target wage.18 We identified two drawbacks to using a single
profile. First, the BLS does not have individual profiles that align
with each Medicaid service. Second, using only one profile may
not give robust enough feedback for whether the target wage will
be competitive with comparable occupations. For example, we
heard reports of rapid wage increases in the food service
industry, which attracted workers from direct care. Using a single
profile does not give feedback about wage changes in occupations
with comparable training and skill requirements. Other states
address these limitations by calculating the weighted average of
multiple profiles to set wage targets.19
We recommend that the division work with stakeholders to

develop composite target wages using more than one occupation
profile. The goal of the composite target would be to provide a
predictable and stable indicator of fair market value for the
services being provided. The division should consider including
codes from competitive occupations to ensure that the wage
targets are not set below the market rate, not just for the specific
set of services being provided but also for the training and skill
level of workers. The U.S. Department of Labor has a point
system for the required knowledge, skills, and abilities by
occupation, which could be used to identify competitive
occupations.
18. The default rule is that the division should find a comparable occupation
profile, and when there is not comparable profile a weighted average hourly
rate is used. IDAPA 16.03.10.037.05(a). For applicable home- and community-
based services, including services provided by developmental disability
agencies, the target rate is set using the occupation profile that most closely
aligns with direct care workers. A weighted average of multiple profiles can be
used if more than one profile aligns. If no profiles are comparable, then the
survey of skilled nursing facilities and intermediate care facility data is used.
IDAPA 16.03.10.038.04.aii—iii.
19. Health Management Associates, Review of States’ Approaches to
Establishing Wage Assumptions for Direct Support Professionals When
Setting I/DD Provider Rates, Prepared for American Network of Community
Options and Resources at 7 (July 6, 2022). This study reviewed the rate-setting
process of 25 states including Idaho.
52
The Legislature should consider requiring the

division to include more information about inflation
costs in its budget request.
Even with well-calibrated wage targets, the current rate-setting
process does not have planned and predictable ways to change
reimbursement rates between cost surveys. Cost surveys for
applicable home- and community-based services are supposed to
be performed at least once every five years. Annually, the division
reviews provider rates to inform its budget request. The process
considers the following factors:
time since the last rate adjustment for a provider group

access concerns as captured in Medicaid complaint
databases
patterns of facility closures
concerns shared by providers during regular meetings
with Medicaid staff
past provider cost survey data
information on Idaho wages from the U.S. Bureau of
Labor Statistics or other data sources
economic factors such as inflation and state tax revenues
As a result of this process, the division adjusted several rates for

direct care services provided after July 1, 2022. Although these
considerations are appropriate, we have concerns that the
division has insufficient management capacity to implement the
process effectively.
Adjusting rates every five years freezes target wages at a single

point in time. As we discussed in chapter five, The more time that
elapses after a cost survey, the more likely rates are to be
insufficient to support competitive wages. In chapter four we
described how businesses often limit the services they provide
and lower the standards of care to compensate for inadequate
rates. The result is cumulative wear and tear in the direct care
industry.
53
The Legislature should consider requiring the division to include a
standing line item in its budget request that incorporates the
inflationary costs of direct care services. The division already takes
a similar approach in its budget request to adjust rates for services
tied to Medicare. The request could be based on the wage targets in
cost surveys, which are usually updated annually based on BLS
data and wages at nursing homes and intermediate care facilities.
The Legislature would then be regularly informed about the
increased cost of services.
As with all budget requests, the Legislature would retain its

authority to approve, amend, or deny the request. However, if the
request were approved, the budget would likely stabilize because
there would be less dramatic rate adjustments following cost
surveys. The division would continue to use cost surveys to rebase
and adjust the supplemental component to the rate to account for
changes in benefits, taxes, program, and administrative costs.
The Legislature could also consider whether to include statutory

intent language that directs businesses to use inflationary
increases for wages. Intent language like this was included in
H382, passed in the 2021 session, which stated that increases
“shall be used solely for temporary pay increases or bonuses for
direct care workers.” A 2020 report from the Saint Louis
University Research Institute found that 22 states had laws
requiring that a flat amount or percentage of reimbursement go to
workers.
The Legislature should consider allowing the division

to set region-specific rates when doing so would
address access issues.
Our estimates of the workforce gap in chapter 2 showed that the
gap was not uniform throughout the state. An adequate rate in
some communities may be inadequate in others, particularly in
communities that border Oregon or Washington where direct care
employers receive a much higher Medicaid rate than Idaho pays
and therefore can support higher wages.
In Medicaid Rate Setting, we recommended that the division’s rate

review include a consideration of whether services would be
enhanced by allowing region-specific rates. In Idaho’s Public K-12
Classified Employees, we suggested the Legislature consider
adjusting the state’s financial support to schools based on location.
We reiterate these suggestions and emphasize that the regional
variation in the workforce gap makes payment for direct care a
particularly strong candidate for region-specific rates.
54
We recommend the division improve transparency in

setting rates for the self-directed model.
Policies and procedures that affect worker pay should be
transparent. However, we found that the division’s policies for
setting the fair market control for the self-directed model is not
transparent.20
The self-directed model is based on the concept of self-

determination. The model emphasizes “freedom for the
participant to make choices and plan their own life.”21 People
enrolled in the self-directed model have the responsibility to
recruit, hire, and train their direct care workers. They may
negotiate how much to pay workers so long as three conditions are
met: 1) payment “does not exceed prevailing market rate,” 2)
payment is “cost-effective when compar[ed] to reasonable
alternatives,” and 3) payment does not exceed the approved
budget.22
People enrolled in the self-directed model submit a plan detailing

the workers they will hire and the negotiated pay. The division
determines whether the proposed pay complies with rule. Rule
does not prescribe how the prevailing market rate is to be
determined. The manual that explains how to compile the plan
makes only a vague reference to the Idaho Department of Labor as
being a good resource in determining a “fair market rate.”
People on the self-directed plan and family members raised

concerns that this process goes against the model’s goal of
ensuring choice. The division reported using several sources to
create a fair market rate.
The division should make publicly available what the baseline

fair-market rate is, how that rate was calculated, and any
additional factors it will use to make the final determination about
whether negotiated payments comply with rule for direct care
workers and other providers, such as support brokers.
Transparency will increase trust among people who rely on
services, family members, and advocates and provide the division
with an opportunity to incorporate specific feedback.
20. This model is also called consumer-directed or family-directed.

21. IDAPA 16.03.13.010.09.a
22. IDAPA 16.03.13.120.03
55
The Department of Health and Welfare
should support efforts to make training
more accessible and develop a career
ladder for direct care workers.
Direct care workers support people in different settings and
across various programs within and outside of Medicaid. Since
direct care workers are not licensed, they do not fall under a
uniform training and testing standard. Instead, a worker could be
subject to several combinations of initial and ongoing training
requirements depending on the setting in which they provide
care, their job responsibilities, the needs of the people they work
with, and the payment source. Training can also be costly.
The Department of Health and Welfare’s Division of Licensing

and Certification oversees standards related to the licensure and
certification of providers, regardless of revenue source. The
division has training publicly available on its website for
providers it oversees.
The Division of Medicaid’s Bureau of Long Term Care recently

received a grant to offer free online training to direct care
workers. The bureau aims to create different levels of certification
and track when workers have gone through the trainings. A
statewide learning management system and career ladder has
also been recommended for the Bureau of Developmental
Disabilities by their community advisory group, Community Now.
Community Now emphasized the need for training to come with
wage increases for direct care workers. It has also provided a
training plan for direct care workers who support people with
intellectual and developmental disabilities. The Bureau of
Developmental Disabilities has not yet made any decisions
regarding Community Now’s recommendations.
56
We recommend that the department expand existing

efforts to make training more accessible and
develop a career ladder for direct care workers.
Direct care workers and businesses may benefit most from a
learning management system with courses that meet the training
requirements for the Division of Medicaid’s programs as well as
the Division of Licensing and Certification’s standards. The
department could consider treating efforts by the Bureau of Long
Term Care as a pilot for expansion to eventually include training
standards from the Bureau of Developmental Disabilities and
Division of Licensing and Certification.
57
The Division of Medicaid must improve its
capacity to manage a program of its size
and complexity.
In our 2022 evaluation, Medicaid Rate Setting, we found a long-
standing deficit in the management capacity to effectively
implement the Legislature’s policy in a complex and expensive
program. We recommended that the division identify its most
urgent staffing needs and include a budget request for the 2024
legislative session.
The division did not request funding for staff in its FY2024
budget. This evaluation revealed the continuing consequences of
not having adequate management.
We reemphasize the importance of our 2022

recommendations for the Division of Medicaid.
The division should identify its key management needs and
submit a budget request to address those needs. The division
should operationalize its measures of access, quality, economy,
and efficiency based on Idaho’s priorities and embed these
measures in the rate-setting process.
58
The Legislature could expand access to

direct care services outside of Medicaid.
The Commission on Aging and area agencies on aging provide
services including housekeeping and caregiving support for
family members who need respite. The commission and agencies
recently piloted a consumer-directed program in some parts of
the state to expand access to care for people of all ages with a
significant disability, special need, or chronic illness. The
program served 99 people by providing over 3,500 hours of care
between September 2021 and February 2022. By allowing
families to hire their neighbors and friends, the program brought
new people into the direct care workforce to address short-term
needs. Consumer-directed respite improved the ability of
caregivers to provide care at home and manage stress and
burnout, according to a study by Boise State University’s Center
for the Study of Aging. The Legislature could consider increasing
resources for consumer-directed programs for respite and
homemaking, or other support services coordinated through the
Commission on Aging.
59
More strategies could be considered to
support direct care workers over the next
decade.
Many other strategies have been developed to professionalize
direct care, improve data collection, create resource centers, and
promote public awareness. Several national advocacy groups have
compiled their recommendations for state policy. The following
reports may serve as helpful references for long-term discussion
about state strategies:
National Conference of State Legislatures, Supporting

Direct Care Workers: Recruitment and Retention
Strategies (Updated April 1, 2022), https://www.ncsl.org/
health/supporting-direct-care-workers-recruitment-and-
retention-strategies
National Governors Association, State Strategies for

Sector Growth and Retention of the Direct Care
Health Workforce (September, 2021), https://
www.nga.org/publications/state-strategies-for-sector-growth-
and-retention-of-the-direct-care-health-workforce-2/
Milbank Memorial Fund, Direct Care Workforce Policy

and Action Guide (May 18, 2022), https://
www.milbank.org/publications/direct-care-workforce-policy-
and-action-guide/
PHI, State Policy Strategies for Strengthening the Direct

Care Workforce (April 11, 2022), https://
www.phinational.org/resource/state-policy-strategies-for-
strengthening-the-direct-care-workforce/
Centers for Medicare and Medicaid Services, National

Evaluation of the Demonstration to Improve the
Recruitment and Retention of the Direct Service
Community Workforce, prepared by RAND Health
(2009), https://www.rand.org/pubs/technical_reports/
TR699.html
60
61
A Request for
evaluation
Sen. Michelle Stennett
62
63
64
Evaluation Scope B
This study aims to assess the impact of state programs,
regulations, policies, and funding decisions on the direct care
workforce. We will describe the network of state and private
agencies, programs, and job titles that support direct care and
answer the following questions:
1. To what extent is there a gap between the needed or approved

level of direct care and what is being delivered?
a. How many people are receiving direct care through

federal or state-funded sources?
b. How does the level of services approved compare the

level of billed services?
c. How are these numbers expected to change over the

next ten years?
d. What is the current turnover rate for direct care

workers?
e. How many more direct care positions does Idaho need

in the workforce?
f. What mechanisms does the state have for monitoring

gaps in access and quality of care?
2. What is the impact on individuals, families, workers,

agencies, and the state when there is a continuous gap
between the needed and delivered level of direct care?
3. What challenges do agencies face in recruiting and retaining

staff?
4. What challenges do workers face in entering and remaining

in the direct care industry?
5. How can Idaho better support the direct care workforce?
65
C Methods
Summary
To gather information for this study, we employed a mixed-
methods approach that analyzed data from several independent
sources including surveys, interviews, and federal and state
agencies. We also conducted a literature review to contextualize
our findings and to develop recommendations. Finally, we
contracted with RECON Insight Group to conduct an economic
analysis to quantify the gap in the direct care workforce, the
economic impact of the gap, and the estimated cost to correct the
gap.
Our mixed-methods approach reflected the deeply complex

system that is direct care in Idaho. Direct care is not a sphere that
contains clear distinctions. For example, the U.S. Bureau of Labor
Statistics combines the very different jobs of a community support
worker helping an individual with developmental disabilities to
live in the community, an aide who comes into a person’s home to
help for a short period of time after surgery, and a person who
comes to help an older adult with housekeeping under the
occupation Home Health and Personal Care Aides.
Based on the study request, our early interviews with key

stakeholders, and our early literature review, we came to narrow
our focus to the types of services provided through Idaho’s home-
and community-based services Medicaid waivers. These services
focus on long-term services and supports that help individuals
with their activities of daily living so they can stay at home and in
the community rather than requiring institutional care. This
narrowed focus is nevertheless blurred in many areas. For school-
aged children, schools often provide support that combines
educational goals and goals for independent living. Schools
sometimes contract with employers we have identified as direct
care providers, and sometimes bill Medicaid. We chose not to
focus on school-based services, but our surveys and data sets may
nevertheless include them in an incomplete way.
66
Similarly, we chose not to focus on short-term care, such as for

individuals recovering from surgery. Nevertheless, many workers
and businesses who provide short-term care may also provide
long-term care.
All of this complexity and difficulty drawing clear distinctions

between types of direct care emphasized to us the importance of
triangulating evidence from multiple methods to derive our
findings.
Outreach
Direct care services and supports are provided by a loose network
of private businesses and workers. When we evaluate a program
run by a state agency, we can identify those responsible for
implementing the program and have easy access to their contact
information. Beneficiaries of the programs we evaluate are often
disorganized and require an outreach effort; in this study, both
the providers and the beneficiaries of the service required special
outreach efforts to get the information we needed to conduct our
evaluation.
Reflecting this need for outreach, we created a website dedicated

to this project. The site, opedirectcarestudy.com, provided
information about our office, the study, and provided an
opportunity for direct care workers, people who rely on direct
care services, or their families to sign up to be interviewed or to
participate in our survey. We shared the site through social media
and asked key stakeholders to share the site with their contacts.
Interviews
We interviewed a variety of individuals and groups, including
people who rely on direct care services, advocacy groups, subject-
matter experts, and direct care workers. We also visited a
developmental disability agency to do job shadowing.
We used a snowball sampling technique to determine who to

interview. We started with some key groups representing people
receiving services and representing providers and asked them
who we should speak to. We asked the same of the subsequent
interviewees. We also interviewed individuals who filled out the
contact form on our website as independent starting points.
67
To gather additional perspectives, we held a series of focus
groups online, organized by Community NOW! We also had a
follow-up focus group with Community NOW!’s Culturally
Responsive Advisory Group in Spanish.
In addition to independent individuals, we also interviewed

individuals or groups representing organizations, including the
following:
Idaho Council on Developmental Disabilities
Idaho State Independent Living Council
Idaho Commission on Aging
Leadership at Idaho Department of Health and Welfare
Idaho Division of Medicaid, Bureau of Long Term Care
Idaho Division of Medicaid, Bureau of Developmental

Disabilities
Idaho Division of Licensing and Certification
Idaho Workforce Development Council
Idaho Division of Veterans Services
DisAbility Rights Idaho
Idaho Parents Unlimited
Idaho Federation for Families
Idaho Caregiver Alliance
AARP Idaho
Idaho Association of Community Providers
Idaho Health Care Association
Idaho Continuum of Care Alliance
Idaho Hospital Association
ACCSES-Idaho
Molina Healthcare
centers for independent living
68
area agencies on aging
direct care businesses
University of Idaho’s Center on Disabilities and Human

Development
Boise State University’s Center for the Study of Aging
PHI
ACLU of Idaho
Survey
We distributed two surveys to get a broad range of perspectives
about direct care in Idaho. We derived our survey questions from
several sources, most notably PHI’s Arizona Paid Caregiver
Survey Instrument used in their report Insights from the
Frontline: Results of a Statewide Survey of Paid Caregivers in
Arizona.
The first survey was tailored to administrators and sent directly

to Department of Health and Welfare’s main contact for the
business. We sent the survey to 784 businesses with valid email
addresses. We received 191 responses, 129 of which were
complete. We received 39 responses from businesses outside the
intended scope of the survey.
The second survey was open to the public, targeted at direct care
workers, people who rely on direct care services, their families,
and others in the system of care. We distributed the survey to
individuals who signed up on our website and through social
media. We also contacted several groups we believed to be well
connected in the industry and asked for their assistance
distributing the survey. These included individual providers, area
agencies on aging, support brokers, and advocates representing
direct care businesses, people who rely on direct care services,
and their families. To encourage participation, we offered five
$50 Visa gift cards. In addition, we organized and delivered a
paper Spanish-language survey with postage paid responses to
accommodate non-English speakers. We received 1,227
responses to this survey. After removing duplicate responses
identified using email and IP addresses, we had 982 responses.
About three-quarters of these were from direct care workers.
69
Another tenth of responses were from people who rely on direct
care and unpaid caregivers.
Limitations
As discussed in chapter 1, the direct care workforce is not a well-
defined group of people and we did not have contact information
for every worker. We relied on outreach on our website and social
media, as well as an extensive network of advocates, government
agencies, and providers to distribute our survey to workers.
While our response rate was higher than comparable efforts, we
nevertheless want to caveat our survey methods.
We did not control messaging that may have been forwarded to

workers along with our survey, unless the workers were
contacted directly. An unrepresentative sample of workers may
have received our survey based on the characteristics or
motivations of those we relied on to distribute the survey.
Using a convenience sample also means that we were more easily

able to contact certain types of workers. Operators of certified
family homes, who we contacted directly, comprise about 10
percent of the direct care workforce but were 37 percent of our
direct care worker respondents. Their responses are filtered out
when appropriate. Conversely, we had no way of contacting the
employer of workers who were directly employed by people who
rely on direct care services and the perspective of those workers
is likely underrepresented.
Literature review
To contextualize our findings and develop recommendations, we
conducted a literature review of over 80 reports published by
agencies in other states about the direct care workforce. We also
reviewed reports published by the National Association of Direct
Support Professionals, the Medicaid and Children’s Health
Insurance Program Payment and Access Commission, PHI,
Centers for Medicare and Medicaid Services, and the RAND
Corporation.
70
Economic analysis
We hired RECON Insight Group, which included two economists
with the University of Idaho and Washington State University, to
conduct an economic analysis. We sought to understand
whether labor market data indicated the existence of a
gap in the direct care workforce, relative to
expectations;
the size of the gap in terms of missing jobs; and
the cost for Medicaid to fill the gap and the economic
impact of doing so.
The analysis used data from the U.S. Bureau of Labor Statistics,
Lightcast, and the American Community Survey from the U.S.
Census Bureau to derive the size of the labor market gap and the
wages necessary to close the gap. IMPLAN, an input-output
model, was then used to derive the economic impact of the gap in
terms of direct, indirect, and induced demand.
Our economic analysis estimated the number of direct care jobs

needed to reach national staffing ratios given the share of
Idahoans who are older adults and people with disabilities.
Although we do not expect Idaho to mirror the national labor
market more broadly, direct care and other occupations that
provide basic public services and health care usually have little
variation across states after accounting for demographic
differences.
Our economic analysis did not estimate the number of direct care
workers needed to meet demand. Since people may not be able to
access needed services, we do not have sufficient information to
determine the demand for services. Frequently cited national
estimates of the shortage are conservative for this reason as well.
Limitations
It is worth noting a few limitations that affected our estimates.
First, national data do not include a unique standardized code for
direct care professionals. We used a cross section of industry and
occupation codes to hone in on direct care professionals.
71
Second, the occupation codes also do not consistently capture
independent providers who work directly for the individuals
receiving services from one state to the next. In the captured
data, self-employed workers made up about 10 percent of the
occupations we used for our estimates. If these workers were
underreported or captured differently in other states, that would
impact our comparison of Idaho to the national average.
Third, the occupational codes tend to obscure areas where there

may be a heightened need. For example, community support
workers, who specialize in working with people with intellectual
and developmental disabilities, are comingled with the three
codes.
Other data analysis

We received several data sets from the Division of Medicaid,
including 10 years of claims from their Medicaid Management
Information System and data from 2016 forward from each of the
two managed care organizations for billing codes identified as
home- and community- based services. In total, the data
consisted of over 30 million rows.
We also received assessments of individuals on the Aged and

Disabled Waiver or who received Personal Care Services through
the state plan from the Bureau of Long Term Care. These
assessments included information on people’s living situation,
level of need, and authorized units of service.
From the Department of Labor, we obtained ten years of

quarterly salary filings by Medicaid providers providing direct
care.
We combined all of these data sets into a single database to help

answer questions about utilization trends, staffing patterns, the
connection between wages and Medicaid rates.
72
Responses to the
evaluation
Brad Little, Dave Jeppesen, Director

Governor of Idaho Idaho Department of Health and Welfare
Judy Taylor, Director Christine Pisani, Director

Idaho Commission on Aging Idaho Council on Developmental Disabilities
Mel Leviton, Director

Idaho State Independent Living Council
73
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Sustainability of Idaho's Direct Care Workforce (Idaho Office of Performance Evaluations)

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February 2023

Office of Performance Evaluations

Promoting confidence and accountability in state government

Joint Legislative Oversight Committee

David M. Cannon Douglas T. Pickett Ilana Rubel Steve Berch

Our report outlines several recommendations for the Division of

Rakesh Mohan, Director

2. Is there a shortage of direct care workers? ....................... 14

Lauren Bailey 5. Why is the shortage a state policy concern? ..................... 38

Responses to the evaluation ................................................... 73

Direct care is an interdisciplinary field that encompasses a wide

Concern about the direct care workforce prompted the request

We used data from multiple independent sources to answer a

Is there a shortage of direct care workers?

What is causing the shortage?

Medicaid became the primary payer of direct care services for

We found that the Division of Medicaid’s rate-setting process is a

How can the state support a more sustainable direct care

The Department of Health and Welfare could also support

Though often overlooked, caregiving is a crucial part of daily life.

Most caregiving is unpaid. However, demographic changes and

1. AARP and National Alliance for Caregiving, Caregiving in the U.S.

Median age 34.6 37.1 7%

People in the workforce 761,970 894,850 17%

Total population 1,570,750 1,847,770 18%

People with a disability 195,750 233,480 19%

People 65 years and older 196,130 301,200 54%

Source: Office of Performance Evaluations' adaptation from President’s

Who receives direct care?

not qualify for Medicaid. In addition, some short-term

We used data from multiple, independent sources to compare the

Chapter three explains why the shortage exists according to the

Chapter four explains the shortage’s broader effects on Idahoans,

Chapter five explains why the shortage is a policy concern and

Finally, in chapter six, we present our recommendations to help

The supply of direct care workers has been described as a crisis.

3. Bureau of Labor Statistics, Employment by Detailed

Idaho does not have enough direct care

7. We worked with a regional economic consultant, Recon Insight

Region 2022 2032

Another way to assess the workforce gap is to examine the

Home health care 8,843 8% higher concentration

Nursing and residential 7,858 11% lower concentration

Services for the elderly 6,097 45% lower concentration

Source: Office of Performance Evaluations' and Recon Insight Group analysis of

To learn more about sudden shifts in direct care employment, we

3,000 First COVID-

Source: Office of Performance Evaluations' analysis of data from the Division of

We found that the number of workers employed had been slowly

8. To target our analysis, we focused on employers that received

We conducted an independent survey of direct care workers in

9. The center’s survey received 238 responses.

The desire to help other people was not

Types of direct care work

8% I want to become a nurse or other

11% There were paid caregiver jobs available

My friend or family member was also a paid

14% The work hours fit my schedule

39% I cared for a friend or relative