Department of Health and Human Services

The New Freedom Initiative (NFI) was launched in 2001 as a nationwide program to reform the way individuals with disabilities and other long-term care needs receive treatment and services. The initiative emphasizes de-institutionalization and consumer choice, and has led to the development of many programs across the federal government that might support direct service workforce improvement.

Centers for Medicare and Medicaid Services (CMS)

As the primary payer for long-term care, CMS is particularly interested in developing the direct care workforce as a component of its larger efforts to improve the quality of care. As part of the New Freedom Initiative, CMS along with other DHHS agencies have funded several major grant programs relevant to DSW outlined below:

Real Choice Systems Change (RCSC) Grants: Since 2001, CMS has awarded over 330 RCSC totaling $270.3 million in grants to states and other agencies working to improve state LTC infrastructures to enable individuals who have a disability or long term illness to live and participate in their communities. 20 grantees awarded RCSC funding in FY 2001 have one or more initiatives aimed at improving recruitment and retention of Direct Service Workers.

In 2004, RTI International prepared a report, “Direct service workforce activities of the Systems Change grantees” that focuses on the workforce initiatives of these grantees. Among the initiatives were; providing a defined financial contribution to community health centers to cover health care for workers (New Hampshire); developing worker registries (Arkansas, Georgia, North Carolina, Oregon, Wisconsin); delivering training through an interactive web system (Kentucky); career ladders (North Carolina); and developing backup systems (New Hampshire, Minnesota). For more information on what states are doing with their RCSC grants, please visit the Real Choice Systems Change Grants Compendium.

Money Follows The Person Grants: Enacted by the Deficit Reduction Act of 2005, the MFP Rebalancing Demonstration is part of CMS’ comprehensive, coordinated strategy to assist states and stakeholders to make widespread changes to their long-term care support systems. In January of 2007, CMS awarded grants to 30 states and DC. The awards represent $1.4 billion in federal funding and 37,731 individuals transitioned out of institutional settings over the five-year demonstration period. In designing their MFP demonstrations, states are encouraged to focus on increasing and training their community workforce to increase the quality, the quantity, and the empowerment of direct care workers. Although DSW has not been a major activity identified in states' initial Operational Protocol, it has been identified as an area of great technical assistance need.

National DSW Resource Center Intensive TA: The DSW Resource Center provides individualized technical assistance (TA) to up to five state Medicaid agencies each year from 2006 through 2008. The purpose of this TA is to help states develop or implement initiatives that strengthen the workforce that supports individuals with disabilities who live in home and community based settings in their states. Intensive TA was awarded to the following states:

2006: Arizona, South Carolina, Texas, Louisiana, and New York
2007: Georgia, Utah, Wisconsin, New Jersey, and North Carolina
2008: Delaware, Indiana, Michigan, Ohio, Vermont

Direct Service Workforce Improvement Demonstration: In both 2003 and 2004, CMS awarded five states Direct Service Workforce Improvement Demonstration Grants to “test the effectiveness of different workforce interventions on the retention and recruitment of DSWs.” Grants were awarded to New Mexico, Delaware, Maine, Louisiana, and North Carolina in 2003 and to Washington, Virginia, Indiana, Kentucky, and Arkansas in 2004. Grantees have focused on implementing health care coverage, training, targeted recruitment, and career ladders. Several grantees are also recruiting non-traditional populations such as older adults and individuals with disabilities (Arkansas), and family caregivers, TANF participants, and displaced workers (Virginia) to work as DSWs.

In addition to the grantees’ own evaluation activities, CMS is funding a national evaluation of all 10 interventions, and is publishing two studies of promising practices that have emerged from the demonstration grants. Among the promising practices highlighted are computer based registration and referral, realistic job previewing, structured interviewing, and expanding health coverage for direct service workers.

For more information on these projects, please visit Demonstration to Improve the Direct Service Community Workforce: An Update.

CPASS Grants: Among the RCSC grants is the CPASS grant, which promotes consumer-directed supports in communities. The grant focuses on changes necessary in the knowledge, skills, and ability of agency-based providers, emerging independent providers, and the community at large to facilitate consumer-directed supports.

Colorado received a CPASS grant in 2002 to design and implement consumer-directed services. That same year, Indiana received CPASS funding to develop a model for the state’s consumer-directed personal assistance services and the infrastructure needed to support it. In 2001, Oklahoma used CPASS grant monies to recommend modifications to the state’s Home Care Act and the Nurse Practices Act that were needed to ensure that consumers could legally assume employer responsibilities for their personal services workers and self direct their care.

Nevada’s 2001 legislature mandated that all residents of Nevada requiring assistance with activities of daily living be identified and their needs addressed. CPASS grant money was used in Nevada to create a statewide network of personal care services and to develop consumer-directed personal assistance strategies. Since that time, the state legislature has approved funding to reduce the waiting list time for personal assistance services and other waiver programs for persons with disabilities.

Ticket to Work Medicaid Infrastructure Grants: These CMS grants focus on increasing employment for individuals with disabilities through the expansion of personal assistance services and the adoption of the Medicaid Buy-In, which is an optional Medicaid eligibility group for workers with disabilities. In 2008, 40 States were awarded MIGs of which 33 also had a Medicaid Buy-In.

Office of the Assistant Secretary for Planning and Evaluation (ASPE)

ASPE Direct-Care Workforce Initiatives: The Office of the Assistant Secretary for Planning and Evaluation (ASPE) is the principal advisor to the Secretary of the U.S. Department of Health and Human Services on policy development, and is responsible for major activities in policy coordination, legislation development, strategic planning, policy research, evaluation, and economic analysis. Since the 1990's, ASPE has made the long term care workforce a major focal point of its policy research agenda. ASPE's external funding opportunities typically take the form of contracts, grants, and cooperative agreements. Within the past few years, ASPE has funded a number of timely direct care workforce initiatives:

The National Nursing Assistant Survey
The National Home Health Aide Survey
Home Health Aide Partnering Collaborative Evaluation
A Survey of Frontline Supervisors Participating in Better Jobs Better Care
Ensuring a Qualified Long Term Care Workforce: From Pre-Employment Screens to On-the-Job Monitoring
The Suitability of TANF Recipients as Potential Long Term Care Workers
Recent Findings on Frontline Long Term Care Workers: A Research Synthesis
The National Symposium on the Recruitment & Retention of Direct Care Workers
The Future Supply of Long Term Care Workers in Relation to the Aging of the Baby Boom Generation
State-Based Initiatives to Improve Recruitment & Retention of the Long Term Care Workforce
State Wage Pass Through Legislation: An Analysis

For additional information on ASPE’s workforce projects, you can read about their ongoing Research Projects or Paraprofessional Long-Term Care Workforce.

TANF/Welfare to Work

States can choose to use TANF block grant funds for worker training, skills training, education, and job searching. Using TANF funds for direct service workforce initiatives will be discussed in more detail in the section of this report on State Funding.

Health Resources and Services Administration (HRSA)

HRSA’s Bureau of Health Professions administers a National Center on Health Workforce Analysis and programs designed to address health professional shortage areas. HRSA also sponsors the Area Health Education Centers (AHEC) program, a long term initiative based on academic-community partnerships that train health care providers.

Agency for Healthcare Research and Quality (AHRQ)

The mission of AHRQ is to improve the quality, safety, efficiency, and effectiveness of healthcare for all Americans. AHRQ seeks to further its mission through two separate grant programs, one for large and one for small conference support. AHRQ is especially interested in supporting conferences that include plans and strategies for disseminating conference materials and products to other audiences, beyond the participants attending the event. Such strategies might include, but are not limited to, submitting articles for publication, posting information on a Web site, and seeking formal opportunities to disseminate the conference information through other venues.

For the Grant Program for Large Conference Support, the maximum length of the project period is up to three years and the maximum award amount is $100,000 direct costs annually. There are three submission dates per year: April 12, August 12, and December 12. For more information on Large Conference Support, please see the grant announcement.

For the Small Grant Program for Conference Support, the maximum length of the project period is one year and the maximum award amount is $50,000 in direct costs. There are six application submission dates per year: February 20, April 20, June 20, August 20, October 20, and December 20. For more information on the Small Grant Program for Conference Support, please see the grant announcement.

Substance Abuse and Mental Health Services Administration (SAMHSA)

The recruitment and retention of staff, managers and leaders in the behavioral health workforce are vexing issues that have taken center stage as a program priority at SAMHSA and as a defined action step in the Federal Action Agenda, a SAMHSA-led collaborative of the U.S. Department of Health and Human Services, 8 other departments, and the Social Security Administration. The promise of recovery is an empty promise if there is not an available workforce, large enough and with sufficient competencies, to address mental health and substance use disorders. It is with this mandate that SAMHSA is working to transform the behavioral health workforce by creating an initiative that will be implemented in collaboration with other Federal partners, provider organizations, states, counties, universities and other stakeholders.

The SAMHSA Workforce Development Initiative is funded by all three of SAMHSA’s Centers (CMHS, CSAT, and CSAP) and the Office of the Administrator (OA), to address issues that cut across the disciplines of mental health services, substance abuse treatment, and substance abuse prevention. SAMHSA developed an Action Plan on Behavioral Health Workforce Development as part of their national strategic plan to strengthen the mental health and addictions workforce. This planning resource includes information on workforce development for prevention, treatment, and recovery across the mental health and addiction sectors.