Direct Support Professionals (DSPs) provide personal care, habilitation, and daily support to individuals with intellectual and developmental disabilities in home and community-based settings, and the workforce remains under strain. The National Core Indicators (NCI) State of the Workforce surveys give the clearest picture:
| Measure | NCI-IDD (calendar year 2024) | Aging and disabilities (2023) |
|---|---|---|
| Who is covered | DSPs serving people with intellectual and developmental disabilities | Direct service workers serving older adults and people with physical disabilities |
| Agencies surveyed | 3,936 in 26 states and D.C. | More than 1,200 in 6 states |
| Workers represented | 344,179 DSPs | More than 1.4 million direct service workers |
| Average turnover | 37% (state range 17% to 54%) | 48% |
| Median hourly wage | $18.39 | $16.00 |
| Agencies paying a median wage more than $0.50 below their state's living wage | Not reported here | 99% |
| Agencies offering health insurance | 57% | Not reported here |
| Agencies offering employer-sponsored retirement | 54% | Not reported here |
| Agencies offering paid time off | 70% | Not reported here |
| Agencies that turned away or stopped referrals because of staffing | Not reported here | About one in three |
Why this shortage is different from general healthcare staffing pressure
DSP work is skilled, physically and emotionally demanding, and carries real responsibility, including medication administration, behavioral support, crisis intervention, and personal care. Wages vary by state, tied in large part to Medicaid reimbursement rates, since most DSP positions are funded through Medicaid waiver programs.
This creates a structural bind specific to this workforce: providers can't simply raise wages to compete, because their revenue is tied to state-set reimbursement rates. Wage increases require either legislative/Medicaid rate action or absorbing the cost elsewhere — which most small and mid-size providers can't sustain.
What's actually moving the needle where it's working
States and providers that have made real progress tend to combine several levers rather than relying on wages alone:
- Credentialing that translates to pay. Programs tied to recognized credentials — such as the National Alliance for Direct Support Professionals (NADSP) E-Badge Academy — are increasingly linked to wage differentials, giving DSPs a visible path to higher pay tied to demonstrated competency, not just tenure.
- Reducing turnover's root causes, not just its symptoms. Burnout, inadequate onboarding, and unclear career pathways drive turnover as much as wages do. Providers investing in structured onboarding and defined advancement paths (DSP I/II/III tiers, lead DSP roles, service coordinator pathways) see measurably better retention than those competing on pay alone.
- Benefits are part of the picture. As the table shows, health insurance and retirement coverage are far from universal. Authors of the aging-and-disabilities report call low wages and limited benefits likely contributors to high turnover.
- Advocacy for rate increases is a legitimate operational strategy. Providers who engage directly with state Medicaid rate-setting processes — not just accept rates as fixed — have, in some states, contributed to reimbursement increases that eventually reach DSP wages.
The access consequence leadership needs to keep visible
Staffing shortages limit access to authorized services: about one in three agencies in the 2023 aging-and-disabilities survey reported turning away or stopping referrals because of staffing issues.
Sources: NCI-IDD State of the Workforce 2024 At a Glance; Hiersteiner, Dubois and Plasencia, Innovation in Aging (Dec. 31, 2025).
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