What can be done about staff turnover?

The Milbank Fund offers a series of solutions that policymakers and industry leaders can implement together to improve the direct care sector. 


State and industry leaders need to work together to address the problem of staff turnover in the direct care industry. The Milbank Fund outlines seven different ways states can positively affect the direct care sector, and four areas that states should focus on when determining policy. 

These are just a few different ways state leaders can strengthen the direct care workforce.
  • Coordinate and align consistent efforts across sectors and geographies 

The DCW shortage does not exist in a single geographic area. Therefore, implementing a regional plan will not solve the problem. It may even increase the challenge. Regional changes encourage DCWs to look for work elsewhere. For example, when wages are increased in one sector like nursing homes, workers may move to the higher-paying occupations, further depleting the lower-paying industries. State leaders should encourage a coordinated strategy by executing changes across all boundaries.

  • Break down silos within state agencies and branches

Lack of data sharing, and inter-governmental silos present barriers to outreach efforts to DCW. State leaders can break down silos by coordinating work across state agencies (e.g., Medicaid, Aging Departments, Labor Departments) but also across branches of government (e.g., executive branch and legislators) which lead to greater accountability and more integration. Both branches can work collaboratively; the executive branch can provide data and offer ideas and experience on potential policy levers, while the legislative branch can then use the resulting data to enact policy. 

  • Standardize wage increases

DCW wages are heavily influenced by Medicaid reimbursement rates. One way to drive wage increases is to also increase reimbursement rates, but these efforts should be monitored to ensure that the funding goes to wages, and not administrative overhead.  

  • Enhance training and competency requirements

The Federal government does not have many training requirements for DCWs. Training standards are set by the state, so those standards can vary across state lines. Providing competency standards for DCWs will help to make DCW performance more consistent from region to region.

  • Avoid unfunded mandates

States can mandate higher wages and training but this is more effective when states can also give providers a stream of funding to help cover the cost of those mandates. Agencies that rely on medicaid reimbursements are particularly vulnerable to being blindsided by unfunded mandates. 

  • Incentivize career pathways

States can regulate training in the home and healthcare sector and even set competency standards that can help guide agency owners towards effective training practices. Standardizing competencies across state regions can also make DCW skills more transferable, which will help them move between sub sectors if they need to. 

  • Improve cost and ownership transparency

States have the power to ensure that funding goes to desirable places. Through cost reporting mechanisms, states can hold providers accountable for how they use taxpayer dollars and ensure that some of those funds are being used to compensate workers fairly.


These are the four areas of action the Milbank Fund suggests state and industry leaders focus on to help reduce staff turnover in home and healthcare. Different states have affected change in these areas with different strategies, but Milbank recommends that they try at least one strategy per area for best results. 

  • Increase wages and provide non-wage benefits
  • Support professionalization
  • Elevate the social value of DCWs
  • Improve data collection, monitoring, and evaluation of DCWs


Increasing wages unsurprisingly makes the list. One study in New York found that increasing the wages of DCWs from 22,000 to 40,000, would reduce Medicaid enrolment. Furthermore, the economic impact of the wage increase was estimated to net the state $7.6 billion. Providing additional benefits, such as childcare vouchers for DCWs with dependents is especially valuable to DCWs as their work hours change frequently. 

Professionalization in the home and healthcare sector will help to bring greater respect to a workforce often thought of as unskilled labor. Offering opportunities for employees to upskill or continue their education will also give them a clearer pathway to advanced positions in the home and healthcare industry. Agencies should design training and micro-credential programs that promote stackability, portability and provide a pathway to professional advancement. Required training for DCWs also needs to be accessible and unconstrained by the limitations of their unpredictable schedules. The Milbank guide also points out the importance of offering training in multiple languages to maximize caregiver compliance. It explores some state solutions to this problem. It cites Michigan’s Professional Direct Care Workers Association, which attempted to standardize a list of professional competencies at the state level. They believed agencies would be more interested in training programs that were compliant with those competencies.

DCWs have lower Social Value in the United States for a variety of reasons explored in the Milbank Guide. Professionalizing the industry is one way to address that inequity. Many of Milbank's recommendations here focus on improving the quality of service provided by DCWs. Making sure that they don’t work understaffed can help to improve service tremendously. As the quality of care goes up, so does the prestige of the profession in the public eye. Investing in new models of care, such as person centered care, can also go a long way to improve the service. The Milbank guide emphasizes the importance of protecting the needs of DCWs so they are in a better position to do their jobs well. 

Data Collection makes every other solution proposed by the Milbank Fund more viable. Policy makers understand that they need more DCWs, but they may not understand why there’s a shortage. Making a more concerted effort to track the experiences of DCWs can help to improve the effectiveness of state policies. Exit interviews are a viable strategy for collecting data on worker experiences. States can also track the performance of newer healthcare programs to gauge their success. Tracking that data can help states work together and learn from each other’s successes and failures. 


Keeping and acquiring talented staff in the home and healthcare sector is one of the most persistent challenges of running an agency. Milbank’s guide is a useful tool for both policy makers and agency owners trying to recover from the great resignation.   

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