LIVING WELL CROSS-SITE EVALUATION 2020-2021 1

Strategies for Building Capacity

of the Direct Support Workforce 

Living Well Grant Background

Variations in access to and quality of home and community-based services 

(HCBS) across the country can put the wellbeing of people with intellectual and 

developmental disabilities (I/DD) living in their communities at risk. To address 

these pressing needs, the Administration for Community Living (ACL) issued Living 

Well-Model Approaches for Enhancing the Quality, Effectiveness and Monitoring of 

HCBS for Individuals with I/DD (Living Well) grants, with two key goals: 

• Increase community integration and independence of individuals with I/DD; and, 

• Improve the quality of HCBS. 

ACL administers Living Well grants through the Projects of National Significance program. ACL 

awarded eight five-year grants across two cohorts in 2017 and 2018 to identify, develop, and 

evaluate model approaches that address the two goals. Grantees are located in the following 

states: Alaska, Georgia, Idaho, Indiana, Missouri, New Hampshire, Virginia, and Wisconsin. ACL 

contracted with the Lewin Group, as a sub-contractor to New Editions Consulting, to conduct a 

cross-site evaluation of the eight grants.1

Each Living Well grantee is building the competencies of direct support professionals (DSP) and 

the capacity of HCBS providers to improve access to and quality of HCBS.2 This brief focuses 

on strategies the Living Well grantees are utilizing to increase the capacity of the DSP workforce. 

Throughout this brief, the recipients of Living Well grants and their respective project teams are 

referred to as “grantees.”

This brief focuses on 

strategies the Living 

Well grantees are

utilizing to increase

the capacity of the 

DSP workforce.

Background: The Need to Strengthen the DSP Workforce

Direct support professionals play a critical role in providing HCBS services and supporting 

individuals with I/DD to live independently within the community.3 However, with significant 

challenges to recruiting and an average turnover rate of 46% within the DSP workforce, the 

demand for DSPs far exceeds the supply. The gap between supply and demand is expected 

1 For more detailed information on the Living Well grant, grantees, and full evaluation findings, evaluation reports can be found here: 

https://acl.gov/programs/program-evaluations-and-reports

2 Living Well-Model Approaches for Enhancing the Quality, Effectiveness and Monitoring of Home and Community Based Services for 

Individuals with Developmental Disabilities; HHS-2017-ACL-AOD-DNIQ-0221. https://acl.gov/grants/living-well-model-approachesenhancing-quality-effectiveness-and-monitoring-home-and-1

3 President’s Committee for People with Intellectual and Developmental Disabilities; America’s Direct Support Workforce Crisis: https://

acl.gov/sites/default/files/programs/2018-02/2017%20PCPID%20Full%20Report_0.PDF 
LIVING WELL CROSS-SITE EVALUATION 2020-2021 2

to widen.4 Barriers to creating a stable workforce include low wages, limited career growth 

opportunities, minimal trainings, ineffective supervision, and growing complexity in work.5

Building Capacity of the DSP Workforce 

Grantees are using data to identify challenges and interventions for the DSP workforce. 

Additionally, grantees are using innovative strategies to improve DSP recruitment, retention, and 

training. This brief highlights examples from several Living Well grantees that can be scaled or 

replicated in other states.

Collecting and Analyzing Data on the DSP Workforce

Overview

While the DSP workforce is experiencing challenges across the country, there is great variation 

across HCBS providers in the wages, benefits, and career opportunities provided to their DSPs. 

Additionally, limited data are available linking outcomes (e.g., reduction in critical incidents, progress toward individual goals, increased staff satisfaction) to training. The Georgia Living Well team 

designed a robust model to enhance DSP capacity, which relies on data collection and analysis.

Example: Georgia

Each year, the Georgia Living Well team distributes an annual DSP staff survey 

to the five provider partners that participate in the Living Well grant. This 

survey, now in its third year of data collection, assesses the type and nature 

of services provided, DSP participation in staff training, staff retention and 

turnover rates, National Alliance for Direct Support Professionals membership, 

and staff compensation, including data on hourly wage, bonuses, and 

incentives. The data are analyzed and compared across the five participating 

provider agencies and against the national average as determined through the 

National Core Indicator survey. Key trends from this analysis enable providers 

to review their current performance in comparison to other providers in the 

state and across the country and identify areas to target for improvement. 

The Georgia Living Well team uses data from their annual DSP staff survey, Therap6, 

and the College of Direct Support (CDS)7 to conduct a comparative analysis. This 

analysis allows the team to better understand the impact of the trainings and 

interventions on each DSP by comparing their CDS coursework and completed 

trainings against the number of incidents reported in Therap, their progress toward 

the goals of individuals with I/DD that they support, and their staff survey responses. 

4 Impact; The Direct Support Workforce Crisis: A Systemic Failure. https://ici.umn.edu/products/impact/311/Systemic-Failure/#Systemic-Failure 

5 National Core Indicators Staff Stability Report. https://www.nationalcoreindicators.org/upload/core-indicators/2018StaffStabilitySurveyReport.pdf

6 Therap is a comprehensive electronic monitoring system that collects incident reporting, medication management, and goals and 

outcomes data at the individual, program, and provider level.

7 The CDS is an online training curriculum designed for the direct support workforce. The Georgia Living Well team is using CDS to 

develop sustainable career pathways and build capacity among direct support professionals (DSPs) and frontline supervisors.
LIVING WELL CROSS-SITE EVALUATION 2020-2021 3

Intended Outcomes

The Georgia Living Well team seeks to establish baseline measures across their provider partners, 

enable providers to assess their performance as it relates to other providers in the state and to the 

national average, and illustrate if and how their grant model contributes to improving the quality of 

life for individuals with I/DD. The Georgia Living Well team is fostering transparency and collaboration among provider partners to address workforce shortages across the state of Georgia. This 

data will additionally inform and refine the Georgia Living Well team’s interventions around the DSP 

workforce and will serve as the foundation for an upcoming community of practice.

Recruiting and Retaining a Quality DSP Workforce

Overview

Factors that contribute to high attrition of DSPs from the workforce include insufficient 

training, limited growth opportunities, and poor compensation packages. Numerous provider 

organizations additionally reported losing staff to other minimum-wage and entry level industries 

(e.g., retail, fast food) due to more favorable benefits and working conditions. Additional barriers 

exist to recruit individuals into the workforce, including lack of awareness of the field and realistic 

job previews. Grantees developed strategies to recruit qualified individuals into the workforce and 

improve the conditions of the workforce to assist in retention.8

Example 1: Idaho

The Idaho Living Well team formed the bFair 2Direct Care Workgroup, which

brings together service providers, direct support workers, self-advocates,

parent advocates, and representatives from the Idaho Department of

Health and Welfare to develop a series of recommendations to increase

the retention, skills, and knowledge of the direct support workforce. The

workgroup is in the process of developing a set of recommendations to 

improve the state’s DSP workforce based on evidence based practice. To 

date, the workgroup has developed a comprehensive list of required DSP 

competencies, developed a plan for necessary changes in Idaho policy 

related to provider qualification, incentives, and training requirements. The 

workgroup will develop a DSP code of ethics, and support the policy 

changes through the legislative process. The measurable intended outputs 

of the bFair 2Direct Care workgroup include a final list of required DSP 

competencies, a summary report of DSP workforce training and incentive 

models, a revised code of ethics in rule, an established fee structure and 

incentive process, a compendium of evidence based knowledge and 

performance standards, an updated training plan, and the statewide 

adoption of a new online training platform.

8 Impact; The Direct Support Workforce Crisis: A Systemic Failure. https://ici.umn.edu/products/impact/311/Systemic-Failure/#Systemic-Failure
LIVING WELL CROSS-SITE EVALUATION 2020-2021 4

Example 2: New Hampshire

The New Hampshire Living Well team partnered with Gateways Community 

Services, the PLUS Company, Community Support Network Inc., New 

Hampshire service providers, and Alvirne High School to launch the Care 

and Support pilot program. The Care and Support program provided 11 

high school students an in-depth introduction into the role of a DSP. Through 

this 18-week multi-modal program, students completed coursework and 

experiential trainings that mirror mandatory training for new DSPs. The 

curriculum included direct interaction with DSPs and individuals served, 

role play, and hands-on experiential learning. Through the completion of the 

curriculum, students become qualified to apply for and become a DSP upon 

their high school graduation, having already completed the initial training 

required. Of the 11 students that completed the program at the time of this 

publication, two students have already begun working with families to provide 

respite care, one student is seeking volunteer opportunities with Gateways, 

and one student is seeking employment as a DSP.

Intended Outcomes

By working with both self-advocates and providers to develop a list of minimum DSP competencies, reconfigure the incentive structure, and develop career pathways, the Idaho Living Well team 

ensures that the workforce is being transformed in a way that attracts and retains qualified DSPs 

that best meet the needs of self-advocates. Through the Care and Support program, the New 

Hampshire Living Well team is working with Gateways Community Services to provide students 

with an introduction to the role of the DSP as well as the necessary trainings and tools to enter 

the workforce upon graduation. Gateways Community Services additionally plans to share the 

DSP training model and curriculum with additional technical schools to continue to implement the 

program to recruit additional graduates into the workforce.

Implementing Training and Career Pathways

Overview

As the role of a DSP can be demanding and require complex skill sets, adequately training the 

DSP workforce is critical to ensuring that the DSP is equipped with the appropriate tools and 

skills to perform and excel, and that the individuals with I/DD are receiving quality, specialized 

care that best meets their needs. Grantees work with self-advocates, DSPs, provider organizations, and training platform vendors to update and improve the training structure for DSPs.
LIVING WELL CROSS-SITE EVALUATION 2020-2021 5

Example 1: Georgia

The Georgia Living Well team is using CDS to develop sustainable career 

pathways and build capacity among DSPs and frontline supervisors through 

professional development. CDS is an online training curriculum designed 

for the direct support workforce. The Georgia Living Well team worked 

closely with five local provider agencies to develop three tracks in CDS for 

staff: newly hired DSP track, existing staff track, and the frontline supervisor 

track. To accompany these new tracks, the team created a new provider 

manual that cross-walked the Georgia Department of Behavioral Health and 

Developmental Disabilities training requirements against the applicable CDS 

courses. In addition to the national CDS curriculum, providers can create and 

add their own training content. For example, the Georgia Living Well team 

developed a module on safety precautions during the COVID-19 pandemic, 

and provider partners developed content on person-centered planning, 

community inclusion, and crisis prevention.

Example 2: Idaho

The Idaho Living Well team, through their bFair 2Direct Care workgroup, 

is developing a training and incentive model to help DSPs advance in their 

careers in order to improve retention in the field. The workgroup developed 

a DSP training matrix that includes recommended DSP training modules, 

the associated competencies with each module, the level of training required 

for each topic, specific learning and performance outcomes, and sources of 

existing training material. Throughout this process, self-advocates shared the 

list of competencies they believe should be held by DSPs based on their lived 

experience.

Additionally, the workgroup developed a logic model and plan to incorporate 

a greater emphasis on person-centered thinking, recruit Spanish-speaking 

DSPs to meet the needs of the Latinx population, translate all training materials 

in Spanish, and propose pay increases and increased reimbursement rates 

to align with proposed tiered training levels. The workgroup is working toward 

delivering sustainable and accessible trainings for direct support staff taught by 

self-advocates, family members and professionals. These trainings are guided 

by evidence based practices in person-centered thinking and planning, trauma 

informed care, supported decision making, total and functional communication, 

and principles of positive behavioral intervention supports.
LIVING WELL CROSS-SITE EVALUATION 2020-2021 6

Intended Outcomes

The Georgia Living Well team’s use of the CDS allows flexibility and autonomy of the provider 

organizations to create training tracks that best meets the needs of both the DSPs and the 

individuals receiving services within their communities. The Idaho Living Well team’s approach 

to reimagining and transforming the training structure through the bFair 2Direct Care workgroup 

allows for collaboration across all levels within the workforce, including self-advocates, DSPs, 

providers, and vendors. By increasing the number of professional development opportunities 

and creating a training structure that emphasizes competency-based learning, the grantees 

are equipping the DSPs with the tools needed to be successful and cater to the needs of the 

community.

Conclusion

Living Well grantees have closely reviewed the current challenges to recruiting and retaining 

the DSP workforce within their state and have adapted their approaches accordingly. Some 

strategies employed by the grantees include:

• Establishing baseline provider data and metrics for comparison across the state;

• Utilizing data tools to analyze impact of DSP trainings and interventions;

• Evaluating the current training system and working with self-advocates to recommend 

changes; 

• Providing high school students exposure to the DSP workforce and the trainings and 

certifications needed to enter the workforce upon graduation;

• Allowing provider organizations to create their own training tracks for their DSPs; and

• Reimagining the DSP training structure through active collaboration across all individuals 

involved in the workforce.

The long-standing challenges to building the capacity of the DSP workforce will require a multipronged approach and collaboration across levels of the system. Grantees are evaluating their 

current landscape and working with self-advocates and other stakeholders to recruit and retain 

qualified DSPs in the workforce.