Keep Essential Care: Direct Service Professionals 

Keep Essential Care: Direct Service Professionals 

COVID19 is having an unprecedented impact on the lives of billions of people. But a robust and effective COVID19 response must not be a vehicle for denying access to essential health care services.

NHeLP is fighting to protect access to the range of critical services that people — especially low-income and historically vulnerable communities — need in order to live their lives. Yes, even in a pandemic. Especially in a pandemic.

Medicaid home and community-based services (HCBS) play a crucial role in allowing people with disabilities to live safely at home and in their communities. During the COVID-19 pandemic, as people are asked to “stay put” and congregate settings have become even riskier, HCBS has become more indispensable than ever. HCBS services are delivered by “Direct Service Professionals” (DSPs). Known sometimes as “community support workers,” “home care workers” or “personal care assistants,” DSPs are the workers who actually provide the services in people’s homes.

Effects on Direct Service Professionals (DSPs)

This pandemic will have a profound and direct effect on DSPs. DSP provider availability is already an issue in many areas, and the pandemic will likely exacerbate this problem. DSPs may need to stay home to care for their own families, or get sick or need to self-isolate due to exposure. As we have previously noted, nine out of ten DSPs are women, are more likely than average to be single parents, and often work two or three jobs. Without immediate action to support the workforce, accessing HCBS could become incredibly difficult, if not impossible. Individuals will likely go without essential services, endangering their health and welfare. For those who have informal caregivers, such as family or friends to provide assistance, these caregivers will face additional burdens, if they are even available at all. 

Three steps can protect DSPs, and by extension, home and community based services. 

First, Congress should provide more funds to support DSPs and HCBS services, either via an increased Medicaid match or through grant programs.

Bills have already been introduced to provide much needed funds for states to pay for overtime, personal protective equipment, hazard pay, sick leave and additional training for DSPs, and can easily be included in Congress’ next COVID-19 package. The funding would also be used to recruit new workers and meet the increased demands for in-home supports due to the “stay at home” orders. States have acknowledged that significant numbers of people on HCBS waitlists rely on caregivers who are at risk of serious effects from contracting COVID-19 and funding could help states address this emerging problem by temporarily expanding waivers to meet this need. Congress should also define HCBS broadly, to ensure that additional funding is also available to DSPs who provide services funded via Medicaid state plans, including individuals with psychiatric disabilities. Additional funding, coupled with strong maintenance of effort requirements, could ensure that funding actually flows to providers and that enrollees do not lose services.

Second, the federal government can designate DSPs essential health care workers in any system to allocate personal protective equipment (PPE).

Many home based services involve hands-on assistance that cannot be provided at a physical distance, putting DSPs at risk. This risk is compounded by the fact that DSPs often serve more than one person in a given day. PPE for DSPs not only protects DSPs from infection and reduces spread among DSPs and the people they support, but PPE will also allow DSPs to continue to support individuals who may need to isolate but do not need to be hospitalized, reducing strain on hospitals. However, simply funding PPE is insufficient if there is no PPE to purchase. Administratively or legislatively, the federal government should ensure that DSPs are included in any system of prioritization and allocation.

Third, states can increase rates to providers and change provider qualifications, via existing authorities to change their HCBS programs.

States with HCBS programs through 1915(c) waivers can submit an Appendix K to increase flexibiltites in their waivers and pursue changes to other programs through state plan amendments, 1135 waivers, and other mechanisms. Through these flexibilities, states can support DSPs by funding PPE and necessary supplies; authorizing more hours for individuals so the DSPs have the time to clean and disinfect as recommended; paying for overtime as needed; and increasing DSP pay. Even absent federal action, states should take steps to secure the DSP workforce, protect their health, and compensate them fairly for the increased risks they face. 

Swift federal and state legislative and administrative action is needed to quickly protect the workers who are the backbone of a functioning HCBS system. Funding and flexibility will be key.

Published Blogs in this Series:

Introductory Blog


Home and Community-Based Care

Direct Service Professionals

Maternal Health

Mental Health Services


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