Absence of data complicates Maryland’s direct care crisis

A lack of data is complicating efforts to understand and address chronic home medical care and services workforce shortages in Maryland.

In July, a panel of Maryland-based researchers examined and discussed the lack of critical long term services and support workforce data and how it might be addressed in the region.

A report focused on Baltimore City’s direct care workforce issued in March bears out the need for a closer look. Titled “Long Term Services and Supports in Baltimore: A Framework for Improving Job Quality and Creating a Highly Trained Direct Care Services Workforce,” its central finding is that these jobs generally don’t pay enough to attract and retain the necessary workforce, particularly in light of an aging population that will drive demand for these services for years to come.

The report was co-authored by David Rodwin, a Public Justice Center attorney, and Meg Laporte, executive director of the Maryland Regional Direct Services Collaborative.

Chanee Fabius, an assistant professor of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health, characterized the problem as a national challenge.

“The direct care workforce is not the easiest group of folks to identify or survey,” she said. “Oftentimes (we) have to rely on federally funded, nationally representative data and make assumptions and conclusions about our state.”

It’s an exercise that frequently leads to dead ends.

“It might surprise you that there is almost no publicly available data about the workers that do it,” Rodwin said, adding that the Commission to Study the Healthcare Workforce Crisis in Maryland created by the General Assembly last year recently released its interim report.

“The very first finding is that workforce shortages are difficult to determine with currently available data,” he said.

No standard reporting

Chanee’s research team made an effort to gather its own data in 2021 by surveying approximately 1,000 state Residential Service Agencies in 2021, but only 177 RSA administrators responded.

“We asked about vacancies, whether turnover increased, decreased or stayed the same since COVID, the role of direct care workers, and about support for families of people living with dementia,” she said.

More than half the responding RSAs indicated that three quarters of their clients experienced some type of dementia, but only 14% of those agencies required dementia-related training for their direct care staff, she said.

Other findings of that survey included a limited or nonexistent availability of substitute workers when another worker was unavailable, and a general lack of additional benefits for this workforce when there was a need for them.

“COVID scratched the surface on some underlying issues that already existed,” Chanee said.

A handful of other states have access to more robust data, acknowledged Claudia Balog, assistant director of research at 1199 Service Employees International Union, a union of health care workers.

In New York, for example, providers file cost reports that enumerate salaried and hourly employees, identify job titles and certifications, and also provide information on wages, benefits, overtime, staff counts and vacancies. They also document workers employed as live-in aids or 24-hour cases.

“Washington State has used cost report data for some time, and Texas is beginning to identify its future workforce development needs,” Balog said.

New York, Massachusetts and California have registries of health care workers while other states are communicating more broadly with this workforce.

“They are being more intentional about the types of data we need to collect,” Balog said.

Integration needed

In April, the Biden administration released a proposed rule aimed at improving access to Medicaid home and community-based services by strengthening the workforce and requiring that 80% of related Medicaid payments be directed toward salary, wages, benefits, payroll taxes and other compensation for home care workers.

“States would be required to publish standardized data regarding home care payment rates every other year,” Balog said. “The Biden administration is acknowledging we have a recruitment and retention problem … grounded in wages and benefits. We really need to not only throw money at the problem, but gather the data we need to show that tax dollars are being used in a way that improves access to services.”

In the meantime, however, that access has become even more problematic owing to disruptions caused by the pandemic that can’t even be measured.

Robyn Stone, senior vice president of research at Leading Age, a community of nonprofit aging services providers, said there is some limited data available through Medicaid Plus reports required for nursing homes that could at least shed some light on the Certified Nursing Assistant population.

“The last time national data were collected on CNAs was in 2007, and for in-home care it was 2004,” she said. “We are very far behind.”

She recommended that Maryland emulate what Wisconsin has done with its own workforce surveys, which led to the development of a statewide workforce platform.

“I think there needs to be a total integration around this workforce between the Departments of Health and Labor,” Stone said. “Both have to work together around how we’re going to do a better job of data collection from providers and individuals.”