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An Arizona Direct Care Worker Survey Is Driving Innovation

August 11, 2021

High turnover and widespread vacancies in the direct care workforce are pressing concerns for all states. Long-term care leaders in Arizona are tackling these challenges by centering workers’ voices and experiences in their response.

Four Arizona managed care organizations (MCOs)—the Arizona Department of Economic Security’s Division of Developmental Disabilities, Banner University Health Plans, Mercy Care, and UnitedHealthcare—partnered with PHI in 2020 to survey paid caregivers statewide, with the goal of developing workforce solutions directly informed by workers’ input and insights. (For this project, “paid caregivers” refers to direct care workers in Arizona who assist older adults, people with physical disabilities, and people with intellectual and developmental disabilities who live at home.)

This ambitious endeavor has culminated in a new research report that provides a wealth of data on Arizona’s paid caregivers, along with evidence-based recommendations for stabilizing this workforce.


In Arizona, although a growing population of older adults is driving up demand for paid caregivers, wages for these jobs are not competitive with other industries. Since the state minimum wage increased from $8.05 in 2016 to $12.00 by 2019, home and community-based services (HCBS) providers have vied with fast food and retail employers to attract workers—and they have often lost out.

The state responded in 2018 by requiring MCOs to work with providers in their networks to identify and address workforce challenges. To gather the necessary data to inform these efforts, the four MCOs named above (which all contract with the state’s Medicaid managed long-term care program) turned to PHI to help them survey paid caregivers and analyze the results.


From the start, the MCOs and PHI recognized that a collaborative approach would be essential to generating relevant and actionable survey results. PHI designed the survey tool, and the MCOs and a sampling of workers and HCBS providers had opportunities to review and strengthen it.

To gather responses, the MCOs disseminated the survey to all the HCBS providers in their networks, which in turn sent the survey to their workers. The agencies were promised their own organization-specific survey data at the conclusion of the project, and survey respondents were rewarded with free access to one of three online continuing education courses.

This detailed planning paved the way to success: from late-August to mid-October 2020, 158 HCBS providers disseminated the survey and 4,216 paid caregivers completed it.


The final research report provides a detailed portrait of paid caregivers’ personal backgrounds and employment histories, wages and compensation, experiences with supervision, training and opportunities for advancement, safety at work, experiences with navigating COVID-19 on the job, and job satisfaction. The report also examines the factors that might be driving workers out of this field, which is crucial information for developing recruitment and retention strategies.

The examples below illustrate how PHI synthesized the research findings—along with best practices and evidence from existing workforce interventions nationwide—to inform the final recommendations.

A clear need exists for career pathways.

What did respondents say?  One in five respondents (21 percent) were unsatisfied with their opportunities for advancement—and 29 percent of those respondents were likely to leave their jobs in the next year, compared to just six percent of respondents who were satisfied with their advancement opportunities.

What could MCOs and HCBS providers do? MCOs and HCBS providers could elevate existing opportunities for advancement and innovate new ones—potentially using the Care Connections Senior Aide model as inspiration.

Supportive supervision could help stabilize the workforce.

What did respondents say? Inadequate supervision was associated with higher intent to leave the job. For example, among the 19 percent of respondents who said their supervisors rarely provided positive reinforcement on the job, intent to leave was much higher than for those who received positive feedback frequently.

What could MCOs and HCBS providers do? MCOs could help HCBS providers adopt more supportive supervisory practices by sharing resources on this topic (e.g., the PHI Coaching Approach®) and by promoting and supporting interventions in the field.

Workers want more training opportunities.

What did respondents say? Most respondents were pleased with their initial training, but 61 percent reported they would like additional training in at least one topic. Among those who reporting the need for additional training, nearly one in six expressed high intent to leave.

What could MCOs and HCBS providers do?  MCOs could leverage partnerships with training providers to widely disseminate online and in-person training.  HCBS providers could use this survey data to determine which training topics would be most beneficial to their employees.

The MCOs have already begun to integrate the survey data into their strategic initiatives. The survey results will also soon inform a new marketing campaign, train-the-trainer program, career ladders and lattices model, and more. The MCOs and HCBS providers are also committed to working together to develop a central repository of resources to meet workers’ self-identified training needs.


The Arizona paid caregiver survey findings clearly show that paid caregivers’ job experiences are complex and shaped by a variety of challenges, supports, and rewards. There is no doubt that wages remain a priority concern, but MCOs and HCBS providers in Arizona now have plenty of evidence to help them develop other strategies for recruiting and retaining paid caregivers as well.

The state can also play a key role in helping to realize the recommendations from this research, including through Medicaid funding decisions and other public policy levers. Given that direct care workforce challenges are pervasive nationwide, other states should consider following Arizona’s example by surveying direct care workers as a meaningful step toward transforming their jobs.


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