The Direct Care Workforce: The Infrastructure Our Families Need (An Interview with Ron Carlson by Jeneva Stone)

Ron Carlson [image description: A white-appearing man speaks at a lectern with a microphone]

Given the Biden Administration’s commitment to Home and Community-Based Services (HCBS) and ending Medicaid waitlists, our country will need more and better-trained direct care workers. These home care workers will be vital to the ability of our medically complex and disabled children to survive and thrive in their communities. Direct care workers provide assistance with the tasks of daily living, housework support, activities outside the home, medical support, and other duties.

Ron Carlson is the Executive Director of the Maryland Regional Direct Services Collaborative. With a background in government, public policy, and public health, Mr. Carlson has a great grasp of the issues our families will face as we build support systems for our loved ones.

Tell me about the Maryland Regional Direct Services Collaborative and its mission.

The Collaborative has set its mission to assure the availability of a well-trained direct service workforce to meet the needs of older adults and persons with disabilities across Maryland and DC. The Collaborative got started in 2016 with a regional meeting which brought together key leaders from Maryland Governor’s cabinet, members of the Maryland General Assembly, senior representatives from educational institutions, the hospital and long term care communities, and unions, as well as direct care providers and several provider membership organizations.

The direct services workforce shortfall is not a new one. It had lingered relatively unattended for nearly fifty years. The call to action issued at the 2016 meeting resulted in an agenda being put in place to tackle the key problems confronted in both Maryland and DC. Corrective steps were directed at enhancing worker wages and benefits, strengthening training and education opportunities, and increasing the supply of workers. That agenda continues to evolve with progress being made on each of the key issues. The Collective has also contracted with a research firm to conduct a comprehensive workforce assessment in our region.

What are the biggest challenges to building and sustaining a direct support workforce for children and adults with complex medical needs and disabilities?

If we are to see measurable progress toward accomplishing the mission, I see three big challenges that must be tackled.

First is the imperative to substantially change the levels of public support for the direct services workforce. This change rests primarily, but not exclusively with the Medicaid program. Direct services work is demanding, but the pay is low. An increase in pay levels and the availability of supportive training services are essential.

Secondly, while public and non-profit stakeholders are actively lending support to enable the frontline workforce, noticeably absent is any expressed interest or involvement on the part of the larger business and corporate communities. While the pandemic has underscored an increased importance on the availability of home and community-based services for employees of business organizations, there is an apparent disinterest on the part of the corporate community to invest and strengthen the direct services workforce as a whole. Without meaningful support from this part of the private sector, I doubt we’ll see any appreciable change.

Thirdly, a critically important challenge is that of rebuilding and strengthening training and education programs geared to this frontline workforce. Without more clear and affordable career pathways provided by employer-sponsored internships and apprenticeships, most if not all recruitment and retention efforts will fall far short. One of the building blocks is to enhance the roles carried by the community college. These schools should serve as the centerpiece for training. That is not the case now.

What can our members do in their states to ensure a robust direct support workforce?

Drawing on my experience to date, I’ve learned a couple of things. First, if the workforce is to see changes that make a positive difference, it’s important that both the general public and the public policy makers understand the problem in terms they can personally and professionally understand. This means elevating attention as to how having the right workforce available positively affects children, families and the community. For the policy maker who has to decide where and how funds are to be spent, answering the “return on investment” question is core.

Personal interest stories must be told, retold, and shared via the social networks, the news media, and meetings with legislators either virtually or in-person. The op-ed piece in the Washington Post earlier this month, “My son’s home health worker is the face of infrastructure” is one terrific example. More of these will make a difference. Experience tells us that while legislative change is driven by research and good data analysis, the more powerful change agent is the attention-getting story that touches the policy maker in a very personal way.

A meeting of the Maryland Regional Direct Services Collaborative [image description: A large group of people sit at tables arranged in a square in a community college meeting room.]

Tell me about the Direct Care Workforce Innovation Program which recently passed the Maryland General Assembly. What do you hope it will achieve?

A year ago, Senator Guy Guzzone, Chair of the Senate Budget and Taxation Committee, introduced “The Direct Care Workforce Innovation Program.” Due to the shortened legislative session brought on by the pandemic, Senator Guzzone needed to reintroduce the bill this year. It was easily passed by both houses and then brought to enactment with the Governor’s approval in May.

The legislation will provide a new resource to community-based organizations in the amount of $250,000 each year for the next several years to help them build the needed workforce. The program will be implemented by the end of this year to allow awards up to $50,000 on a matching basis for at least three years. I see this support substantially helping organizations come up with new ways and means for tackling the challenges they face in both initiating and bolstering their recruitment and retention strategies. Very importantly, and in keeping with the objective of building new approaches, the legislation calls for the coordination of these new programs with educational institutions and with the Maryland Department of Health.

It is expected the grant announcement launching the initiative will come sometime this fall. Coincident with the announcement, the Collaborative will conduct a webinar to highlight the program and outline how it will be implemented. For more information on the webinar, check our website and sign up for our newsletter.

What inspired you to become involved in direct services advocacy?

I became involved as an advocate for change while serving as the Donor Representative for the Paul R. Willging Endowment at the Howard Community College in Columbia, Maryland. The Endowment provided scholarship support for students pursuing health care careers in the care of older adults. It wasn’t long before I learned about the direct care workforce problem. While this end of the workforce delivers nearly 60% of patient care in and outside long-term facilities, direct care has a shortfall of 40%. Having spent my career in public health and health care financing, I knew well the issues confronting the acute care and primary care parts of the system, but was unaware of this part of the delivery system. It was astounding to find that so little attention had been given to direct care issues.

By setting up the Collaborative and bringing together a strong cross section of the professional, educational, and business communities, both public and private, I thought that we could and would find the ways to close the gap.

How has advocacy given meaning to your life?

Over the past many years, I have worked to highlight and bring to life a social innovation agenda for positive change. I have long been an advocate to challenge the norms, and to argue for and present ideas aimed at strengthening a community’s ability to address problems, especially those struggling to find pathways to a better quality of life. This has included setting up “the business roundtable” to grapple with the tough issues. It has meant serving on state-wide and county level advisory committees addressing issues to improve population health. It has meant conducting community wide needs assessments to identify shortfalls, and highlight areas where communities can target interventions that work. While the challenges are endless, the occasional victories are personally and professionally fulfilling.

If you could define advocacy in a single sentence, what would it be?

Advocacy is working to bring about those changes in communities that improve the quality of life for those in need.

[This interview has been edited for concision and length.]

Ron Carlson has served as the Executive Director of the Maryland Regional Direct Services Collaborative for the past three years. Previously, he served as research associate with University of Maryland Baltimore County’s “The Hilltop Institute,” and was director of the Policy Analysis Center established by the Horizon Foundation. Mr. Carlson was the president and founder of the Institute for Community Health focused on both community and population health improvement. He earlier served as the director of community health with the Center for Health Policy Studies and was senior researcher for the National Academy of Public Administration. Mr. Carlson was a founding member of the Senior Executive Service and held senior health care policy positions in the United States Department of Health and Human Services for more than three decades.