# Overview of 2024 National Technical Assistance Offerings to Support State Systems-Change Aimed at HCBS Direct Care Workforce Revitalization

The Direct Care Workforce (DCW) Strategies Center, led by the National Council on Aging (NCOA) and funded by the Administration for Community Living (ACL), is excited to announce the availability of several technical assistance opportunities to state governments to facilitate and expedite the implementation of multifaceted strategies to expand, enhance, and strengthen the direct care workforce responsible for providing high-quality home and community-based services (HCBS) to older adults and persons with disabilities. Through the Direct Care Workforce Strategies Center, technical assistance will start in April 2024. Learn more about the purpose and goals of the DCW Strategies Center.

Background 

In late 2022, ACL awarded a five-year grant to establish a national center to expand and strengthen the direct care workforce across the country. In an effort to build from the successes realized through states’ efforts under the American Rescue Plan Act of 2021 Section 9817 to stabilize and build the HCBS direct care workforce, the Strategies Center is now offering federally-supported technical assistance (TA) to states and territories[footnoteRef:1] to facilitate collaboration among state agencies **–** including Medicaid, aging, disability, labor, and workforce development systems **–** and their stakeholders to improve recruitment, retention, training, and professional development of the direct care workers who provide the critical services that make it possible for people with disabilities and older adults to live in their own homes and actively participate in their communities. [1:  States may also include one or more leaders from their HCBS systems representative of stakeholder groups pivotal to HCBS systems change and the direct care workforce in their applications to the Strategies Center for technical assistance, including but not limited to: federally funded aging and disability networks, HCBS provider organizations, entities representing direct care workers, and consumer-led/advocacy organizations. ] 

Under the leadership of NCOA, the Strategies Center has selected the following five organizations representing some of the nation’s leading experts in HCBS policy and program design to help drive its technical assistance initiatives over the 2024 calendar year: ADvancing States, National Association of State Directors of Developmental Disabilities Services (NASDDDS), National Association of Medicaid Directors (NAMD), PHI, and University of Minnesota’s Institute on Community Integration. Additionally, the Strategies Center has recruited a cadre of other national partners[footnoteRef:2] who will provide informational resources and additional subject matter expertise as needed or requested by state teams to assure optimal support of each participating state’s unique objectives and priorities.  [2:  Complete list of the Strategies Center’s partners.] 

Technical Assistance Provided 

Beginning in April 2024, the Strategies Center will provide state governments the opportunity to participate in one of two dynamic technical assistance offerings to help further their state systems-change efforts aimed at building a revitalized direct care workforce to meet the growing demand for high-quality HCBS to support older adults and people with disabilities to age-in-place and live, work, and thrive in their communities of choice. **The two offerings include:**

1. OPTION ONE – Direct Care Workforce Intensive Technical Assistance to States:****This opportunity will provide up to 250 hours of individualized technical assistance for up to six multi-disciplinary state teams. The program will be facilitated by the state association consortium, led by ADvancing States in partnership with the National Association of State Directors of Developmental Disability Services (NASDDDS) and the National Association of State Medicaid Directors (NAMD). States will be assigned to a TA coach and have access to a number of subject matter experts (SMEs) based on state preference and need. State teams will work to complete individualized systems-change TA plans aimed at improving direct care workforce development and retention through reforms in policy, practice, programming, payment, and performance. The states selected will be required to solidify a cross-systems and cross-agency state team composed of representatives from the state’s Medicaid agency, entities responsible for HCBS waiver populations, and programming (including but not limited to developmental disabilities, aging, mental health, physical disabilities, traumatic brain injury, or other state-specific targeted HCBS populations), and workforce development systems.[footnoteRef:3] The participating states will undergo an intensive assessment and readiness action process as part of the TA model.  [3:  Other state agencies/partners (state Temporary Assistance for Needy Families, vocational rehabilitation, housing, higher education, adult vocational education/training) may also be encouraged or required depending upon the goals that the state chooses to focus on and receive technical assistance around.] 

2. OPTION TWO – Direct Care Workforce State Peer-Learning Collaboratives: The Strategies Center will sponsor up to three time-limited, results-oriented, topically-focused working groups of four to six states each. Each state participating in the Direct Care Workforce State Peer-Learning Collaborative will engage in monthly virtual meetings focused on group learning and information sharing on best practices, innovative strategies, and demonstrated models for growing the direct care workforce. In addition, each state will receive a small number of hours (50-70 over the course of PLC) to work with one subject matter expert (SME) of their choosing. It is expected that each participating state will accomplish one policy or program-related milestone within the parameters of the topic of focus as a result of participation in one PLC. 

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Description of Direct Care Workforce Intensive Technical Assistance to States *(OPTION ONE)*

A. TA Timeline:**The first cohort of the Direct Care Workforce Intensive Technical Assistance to States runs from April 1 - December 31, 2024. Any extensions in timeframe are at the sole discretion of the Strategies Center.

B. Scope/Anticipated Activities: States will engage in a TA assessment and planning phase to better understand the state’s current direct care workforce landscape/challenges/resources gaps, identify key TA goals and milestones to be accomplished, and the necessary TA resources required. This will culminate in a detailed TA plan for each individual state. Once plans are developed, states will receive support in completing ongoing structural systems-change readiness activities and targeted TA. The TA will be focused on one categorical area of focus based on the state’s individual interests and needs. In addition to working one-on-one with a TA Coach and select team of designated HCBS direct care workforce SMEs, participating states will engage in at least three virtual meetings of the entire cohort of participating states in the project. Each state will be expected to present initial learnings/results of the TA effort at the ADvancing States’ Annual HCBS Conference, which will be held August 18-22, 2024 in Baltimore, Maryland. By the end of the TA period, each state will receive a comprehensive, detailed report of the work conducted by and between the state and their assigned TA Coach and subject matter expert team during the project period.  

C. State Selection: Up to six states will be selected to participate in the Strategies Center’s 2024 Direct Care Workforce Intensive Technical Assistance to States Cohort, depending upon the number of applicant states and the total amount of resources available. States will be selected based on the following evaluative criteria:

· Confirmation of participation by all required state partners (Medicaid, agencies responsible for Medicaid-funded HCBS programming, labor/workforce development agencies).

· Evidence of previous state focus on improving direct care workforce training, development, and sustainability (i.e. ARPA investments, state investments in direct care career pathways, apprenticeship programs, etc.).

· Demonstrated commitment by state to clearly define systems-change goals aimed at building the capacity of the direct care workforce.

· Engagement of key stakeholders (including direct care workers, self-advocates/consumers, family caregivers, and HCBS providers) to inform state’s systems-change activities to strengthen the direct care workforce, including but not limited to launching/leveraging of a state advisory committee.

· Feasibility of state’s strategy for leveraging the Strategies Center’s technical assistance offerings to further its stated systems-change goals and achieve specific milestones.

D. State Assessment & Readiness Activities:**States will also undergo a Readiness Assessment & TA planning stage over the course of the first 90 days that includes the completion of the following activities:

· Establish a cross-systems state team and establish roles for each of the participating partners and agree on governance structure and meeting cadence.

· Gather the necessary documents requested by the state’s Project Lead Consultant (e.g. state ARPA plans and quarterly updates; state Plan; contact list for state TA team participants; documentation of commitment by state Medicaid agency and state workforce system; any pertinent planning documents/materials confirming state’s previous investments/activities focused on direct care workforce development and sustainability).

· Complete a self-assessment tool.  

· Develop and refine the state TA Plan. 

· Confirm engagement of an existing advisory committee of stakeholders (direct care workers, consumers, advocates, family caregivers, employers) or initiation of a new advisory committee. 

As part of their TA plan, states may build in additional technical assistance to support the completion of longer-term readiness activities (for example, development of cross-agency memorandums of understanding, data sharing agreements, etc.). 

E. Targeted TA Categories: The targeted TA that will be available to the 2024 state cohort include but are not limited to the following categories.

### Leveraging/Aligning Workforce Development Investments & Strategies with State HCBS Program Workforce Goals. 

This targeted TA category will support states in building more robust cross-systems state strategies for strengthening the direct care workforce. Technical assistance will include but not be limited to the following activities intended to leverage education, workforce development, and Medicaid HCBS funding streams and programs toward a common prioritization of the direct care workforce. *[**NOTE:**It is strongly encouraged that states interested in pursuing this targeted TA category also engage their state education agency to participate as part of the state TA team.]*

· Engaging with local and state workforce investment boards and the state workforce development planning process to assure HCBS direct care workforce is prioritized for annual employment and training formula dollars as a high growth industry (HGI); 

· Developing career pathways that are jointly supported/prioritized by the secondary and higher education/workforce development/HCBS systems to assure alignment in requirements (competencies, career ladders/lattices, credentialing) and investments (apprenticeships, advanced role models/strategies, and other work-based learning opportunities); and 

· Drafting of policy guidance regarding blending, braiding and/or sequencing of programmatic funding across education (adult vocational/secondary vocational education/higher education), workforce development/VR and Medicaid/aging/disability to support recruitment, training/professional development, and retention strategies.

### Value-Based Purchasing and Other Financial Strategies to Enhance Recruitment and Retention 

TA will focus on understanding, designing, and developing specific value-based purchasing (VBP) model(s) to promote the recruitment, training/development/career paths and retention of direct care workers. States will be supported in focusing on the specific features of the VBP model they wish to pursue, measures to include, and authority vehicle (if using Medicaid funds) they want to use. It is important that states who select this option understand that development of rate methodologies will not be included in this TA category. The TA will instead focus on helping states assess their own remuneration strategies and identify/implement strategies for promoting quality and tenure of the direct care workforce. Activities under this TA category may include:

· An exploration into demonstrated state VBP models or other quality-oriented payment strategies to identify key learning; 

· Assuring provider equity in VPB model development; 

· Determining what should be included as part of the VBP (training, development, career paths for workers, benefits, other creative ideas); 

· Development of training programs for providers where they receive a rate increase if the training is completed; 

· Determination of VBP design based on fee-for-service (FFS)/ managed long-term services and supports (MLTSS) as state’s current HCBS operational model; 

· Piloting statewide models and their implications; 

· Development of a system for providers to submit requested data and/or record of completed plans/activities to trigger receipt of rate increase or incentive payment; 

· Development of transparency requirement to ensure support goes to direct care workers; 

· Rate increase for maintaining or exceeding a specified % of direct care worker retainment; 

· Evaluation of proposed VBP options. 

### Non-Monetary Compensation Strategies for Supporting Direct Care Workforce Development, Retention, and Well-Being

States will identify common barriers to direct care workforce entry and retention and will work to introduce proven employment models designed to alleviate barriers. Strategies could include peer mentorship, coaching supervision, providing contextualized case management services to connect workers with community-based services, offering childcare and transportation stipends, providing housing assistance and navigation, etc. States will learn about models for designing/implementing these various non-monetary efforts to build, strengthen, and support the direct care workforce, and then from these models will identify specific goals and develop an action plan moving forward with at least one initiative. Topics that will be explored include but may not be limited to the following:

· Creating peer mentoring/support programs; 

· Establishing support hotlines (such as clinical services on demand); 

· Offering a childcare stipend (where appropriate the development of onsite childcare centers, i.e. in adult day programs); 

· Providing housing assistance and transportation vouchers; 

· Instituting educational credits or tuition reimbursement; 

· Establishing a Medicaid (development of a 1915i—or other authority) benefit specifically for direct care workers. 

[**NOTE:** States may also note on their application any other technical assistance that they feel is necessary for the successful accomplishment of their desired goals. Such requests will be considered on a case-by-case basis depending on available resources.]

F. State Requirements:**While the timeline for the completion of the project may be short (the projects should be completed by December 2024), the anticipated outcomes will be significant. As such, robust collaboration in and across participating states is imperative to achieving the expected outcomes of the Strategies Center’s technical assistance offerings. To assure this occurs, participating states are expected to affirm the following:

· States must attest to meaningful engagement of the required partners (state Medicaid Agency, state agencies responsible for HCBS programs, state workforce development agencies) and any additional state partners engaged due to targeted TA topic chosen. States also have the option of inviting other state agencies and partners to engage in the TA but must assure that any additional partners can commit the staff resources to effectively engage in the TA initiative.

· States must be able to commit approximately 10% time among core staff vital to the state’s articulated goals and milestone completion. 

· The state will designate a “state Team Lead” who holds a senior management position, is capable of allocating adequate staff resources to the project, and will devote approximately 10-15 hours per month to this project. The state Team Lead will meet every other week (at mutually agreed upon times) with the Strategies Center’s TA Project Lead Consultant assigned to the state. The state Team Lead will coordinate the work of additional state staff or governance bodies, as needed, for the development of the draft state TA Plan. 

· The state Team Lead will have access to the state Medicaid Director, operating agency directors, and other state leadership as needed for purposes of the TA project and will review and provide feedback on the draft state TA Plan prior to finalization.

G. Direct Care Workforce Intensive Technical Assistance to States Schedule: The schedule for the Strategies Center’s 2024 TA Activities is as follows.

## H. **Core Elements/Activities/Resources available to states participating in TA to States**

Description of 2024 Direct Care Workforce State Peer-Learning Collaboratives *(OPTION TWO)*

As an alternative to the Direct Care Workforce Intensive Technical Assistance to States, the Direct Care Workforce Strategies Center invites states to consider participating in a time-limited, action-oriented, topically focused Peer-Learning Collaborative (PLC). The Strategies Center will host a minimum of two and a maximum of three PLCs annually. In 2024, the Strategies Center will launch at least two PLCs that will meet one to two times per month for up to six (6) months, with opportunities to share progress and learnings. The PLCs will participate in full group virtual sessions with the support of facilitators and subject matter experts to coach and support progress. 

A. TA Timeline:**The Peer-Learning Collaboratives will run for approximately six (6) months starting between April-June 2024 and ending between September-November, 2024.   

B. Anticipated TA Activities: States will engage in an exploratory interview process to clarify or elaborate upon the state’s current direct care workforce landscape/ challenges/resources/gaps, systems-level goals related to direct care workforce development and sustainability, and preferences related to PLC engagement and participation. This information will be used to help the state establish at least 1-2 specific milestones to accomplish as a result of participating in the PLC. States will engage in 6-12 virtual meetings of PLCs. States will also receive some limited individualized virtual TA from a mutually agreed upon subject matter expert (approximately 50-70 hours over the course of the PLC six-month time period). 

C. State Selection: Four to six states will be selected to participate in each of the Strategies Center’s 2024 PLCs, depending upon the number of applicant states and available SME resources aligned with state needs.[footnoteRef:4] States will be selected based on the following evaluative criteria: [4:  A request made by a state to participate in more than one PLC in a single year will be evaluated on a case-by-case basis and determined based on states’ needs, interests, and capacity.] 

· Confirmation of participation by all required state partners (which will be defined depending on PLC topic, but at a minimum is anticipated to include state agencies responsible for Medicaid-funded HCBS programs and workforce development).

· Evidence of previous state focus on improving direct care workforce training, development, and sustainability (i.e. ARPA investments, state investments in direct care career pathways, etc.).

· Alignment of state’s stated systems-change goals with selected PLC topic(s). 

· Feasibility of state’s strategy for leveraging Strategies Center’s PLC to further its stated systems-change goals and achieve specific milestones.

D. State Requirements: States receiving intensive TA through the Direct Care Workforce Intensive Technical Assistance to States will not be eligible to participate in any PLC simultaneously. States selected to participate in a PLC must commit to the following requirements.

· Participating in all group PLC meetings (1.5 hours/meeting, 1-2 times/month), and sharing their experiences and strategies on the topic of focus with peers from other participating states.

· Identifying a key PLC state Team Lead and point of contact, who will be responsible for sharing information with all state partners participating in the PLC (a secondary point of contact should also be identified).   

· Assuring full participation of relevant state partners as dictated by each PLC topic.

· Having representation at the Direct Care Workforce Strategies Center’s State Systems-Change Showcase during the Annual ADvancing States HCBS Conference; 

· Sharing lessons learned, promising practices, and experiences upon request of the Strategies Center’s leadership (examples include: speaking on a Center webinar; presenting at a Strategies Center-led session at a regional or national conference; participating as an SME in a subsequent PLC; or sharing examples of systems change deliverables as a template for other states desiring to make similar changes, which can then be disseminated via the Strategies Center’s website); and 

· Making progress toward one systems-change (policy reform, new partnership, program update, etc.) as a result of their engagement in the PLC.

E. Targeted PLC Topics:******States interested in participating in a PLC will outline their preferences in the application process based on the topics outlined below. *[**NOTE:** Across all PLCs, facilitators and SMEs will seek to address cross-cutting implementation such as urban/rural distinctions, culturally responsive services, and other relevant issues.]*

### Strategies for Cross-Systems Change Partnerships to Support State HCBS Direct Care Workforce Development Goals     

This PLC will focus on supporting cross-systems collaboration among state Medicaid, aging & disability, workforce development, and education agencies to coordinate efforts, streamline processes, and leverage resources toward growing state investment in and prioritization of building a robust pipeline of direct care workers to support growing demand for high-quality HCBS. Topics may include but not be limited to:

· strategies for establishing career pathways for various levels of direct care workers; 

· co-investing in scholarship, apprenticeship, and ongoing peer mentoring opportunities between state adult vocational education/community college systems and workforce development programs; and

· getting the HCBS sector prioritized as a high growth industry in your state for the purposes of leveraging increased employment and training funds to support the DCW pipeline. 

### Developing Reliable Data Systems to Understand Provider Network Capacity & Leverage Direct Care Workforce to Address Care Gaps in Real Time

Effective deployment of a state’s direct care workforce requires a reliable, transparent system for capturing and reviewing data to better understand existing capacity of HCBS providers and to better deploy existing direct care supports in real-time. This PLC will focus on specific strategies states are investing in to:

· improve their provider-related data; 

· develop registries to better match HCBS participants with providers and direct care staff; 

· use trend data to make future projections and inform budgetary and policy conversations; and 

· construct new infrastructure and incentives strategies to address critical care gaps and shortages in real-time. 

### Building a Robust Direct Care Workforce to Support Individuals who Self-Direct HCBS

This PLC will focus on the unique experiences of direct care workers supporting individuals under a self-directed HCBS model, and strategies for building a robust direct care workforce for self-directed HCBS participants. Potential topics include exploring promising practices and lessons learned with respect to:

· increasing training opportunities for DCWs who are supporting HCBS participants under self-direction; 

· introducing or augmenting an “agency with choice” design within HCBS self-direction models; 

· educating and supporting service recipients who wish to pursue self-direction options; and 

· growing the DCW workforce to support HCBS self-direction models.

### 

### Supporting Paid and Informal Family Caregivers

Many individuals receiving HCBS will choose family members to deliver HCBS either as paid direct care staff or as informal, unpaid caregivers (or both). Informed by findings from the RAISE Advisory Council, this PLC will focus on strategies that states can deploy in supporting and developing both paid and unpaid family caregivers to enhance the broader direct service workforce. Topics may include but not be limited to:

· reviewing emerging models like Structured Family Caregiving;

· developing policy guidance to properly manage paid and informal family caregiving structures; 

· removing administrative burden around payment of and support to family caregivers; 

· using electronic visit verification (EVV) to monitor and evaluate trends in family caregiving; and 

· designing/implementing training opportunities and technical support initiatives for family caregivers. 

### Leveraging Technology to Address Direct Care Needs

Several technologies have emerged that show potential for DCWs to deliver services more efficiently and at a greater scale. This PLC will explore the role states have in identifying, vetting, and disseminating promising technologies that enable the current direct care workforce to more effectively support people receiving HCBS to be optimally independent and integrated in their communities of choice while maintaining their privacy and autonomy. 

### Strategies to Support Statewide DCW Recruitment Efforts

This PLC will introduce states to several successful strategies for attracting new populations into the direct care workforce sector. Effective approaches to marketing campaigns, cross-systems collaborations, and strategic investments in provider-based recruitment efforts will all be explored.

## F. Summary of Core TA Components Offered through the 2024 DCW State PLCs

Next Steps for Interested States

Interested states should complete a brief **online application****by****8:00 p.m. Eastern Time on Monday, March 25, 2024**. States selected to participate in the project will be notified by mid-April, and the project work will begin immediately. If you have any questions about your state’s participation in the project, please contact directcareworkforce@ncoa.org.

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