Enhancing Respect and Appreciation: Strategic Approaches to Boosting Retention of Direct Care Workers in Baltimore

Across the country, the struggle to retain direct care workers in long-term services and supports (LTSS) is reaching a crisis point. This article combines insights from a comprehensive Baltimore-focused report with recent research to explore the complexities behind this workforce crisis.

The Baltimore Report: A Spotlight on Two Key Systemic Issues

The recent report released by the Maryland Regional Direct Services Collaborative offers a framework for improving job quality and creating a highly trained direct care and services workforce for organizations serving older adults across the state of Maryland. This report paints a concerning picture of the challenges faced by direct care workers in Baltimore, emphasizing the harsh realities of inadequate compensation and insufficient staffing. These two key issues are central to understanding the dissatisfaction and high turnover rates in the workforce, a shared sentiment experienced by long-term care providers across the nation.

“There are some sectors of the labor force, however, where short staffing is much more than an inconvenience. One such sector is the subject of this report: the direct care and services workers (DSWs) who serve older adults and individuals with disabilities in long-term services and supports (LTSS) settings.” — Maryland Regional Direct Services Collaborative

Inadequate Compensation: Imagine a scenario where direct care workers are paid less than employees at local retail stores or fast-food restaurants. This comparison is stark in Baltimore, where the pay for these vital healthcare roles often does not meet basic living wage standards. For example, if a direct care worker earns significantly less than what is required to cover basic living costs in the city, they may be forced to work multiple jobs or leave the sector altogether for better-paying opportunities. This not only affects their financial stability but also impacts their ability to provide attentive, consistent care to the elderly.

Poor Staffing Ratios: Consider a nursing home where there are too few caregivers for a large number of older adults. This scenario can lead to each worker being responsible for more older adults than they can feasibly manage, increasing stress and reducing the quality of care. For instance, if a caregiver is overwhelmed, they might have less time to spend with each older adult, potentially overlooking critical needs or changes in health conditions. This can lead to errors, decreased quality of life for older adults, and ultimately, a feeling of dissatisfaction and burnout among workers.

“Nearly all DSWs (direct care and services workers) in these settings report dissatisfaction with staffing ratios. Many say that these low ratios make it very difficult to provide the level of care that they want, or are able, to provide.”— Maryland Regional Direct Services

These systemic issues highlighted in the Baltimore report have direct implications not only for the workers but also for the older adults in their care. When caregivers are underpaid and overstretched, it’s not just their job satisfaction that suffers— the quality of care they can provide is also compromised. As a result, addressing these challenges is crucial for improving the well-being of both direct care workers and the older adults who rely on their services.

Let’s Dive Deeper: Compensation and Economic Pressures— the Impact on Direct Care Workers and Older Adult Care

Direct care workers, essential in providing support and care to older adults, often earn wages that do not meet the basic living standards in many areas, including Baltimore. This gap between their earnings and the necessary living wage contributes significantly to job dissatisfaction and high turnover rates in the sector.

Real-World Impact: Considering a direct care worker in Baltimore who earns around $13 per hour, the reality becomes stark when aligned with the SmartAsset 2024 report which identifies the salary needed for a single adult in Baltimore to live comfortably as $84,989 annually. This translates to approximately $40.86 per hour—far above the earnings of many caregivers.

This disparity between actual earnings and the required living wage significantly impacts workers’ financial stability and overall well-being. For example, a caregiver earning less than half the hourly wage needed for a comfortable life might struggle with basic expenses such as housing and healthcare. This financial pressure can lead to physical and emotional exhaustion, impacting their job performance and ability to provide quality care. Consequently, the older adults and  individuals living with disabilities they care for may experience a decline in the quality of attention and support received, affecting their overall well-being and quality of life.

Such economic pressures underscore the critical need for wage adjustments in the direct care sector to ensure both caregiver well-being and high-quality older adult care in Baltimore and beyond.

Broader Implications: This issue extends beyond Baltimore. Research published in The Gerontologist indicates that low pay in care settings is a national problem, affecting the stability of care services across the United States. Workers who are not compensated fairly are more likely to leave their jobs in search of better-paying opportunities. This not only leads to a shortage of experienced caregivers but also impacts the continuity of care for older adults, who benefit from building trusting relationships with their caregivers.

Example from The Gerontologist: Studies have shown that better-paid caregivers are more likely to stay in their roles, which leads to higher continuity of care and better outcomes for the health and well-being of the older adults they support. The quality of care is crucial in settings where older adults rely on caregivers for daily activities, medical needs, and emotional support.

The link between adequate compensation and the quality of older adult care is clear: paying caregivers a living wage is not just a matter of economic fairness but also crucial in maintaining a stable, qualified workforce to care for our aging population.

Staffing Ratios and Worker Burnout: Understanding the Impact

Low staffing ratios in long-term care settings like those in Baltimore mean that there are too few caregivers for a large number of residents. This imbalance increases the workload on each caregiver, leading to physical and emotional exhaustion, commonly known as burnout. For instance, a caregiver responsible for too many older adults may not have enough time to adequately attend to each individual’s needs, which can lead to mistakes, reduced quality of care, and ultimately dissatisfaction with their job.

Burnout not only affects the caregivers’ health and job satisfaction but also impacts the quality of care that the older adults receive. Caregivers under stress may not be able to provide the compassionate, attentive care that is crucial for the well-being of older adults. Addressing staffing ratios by hiring more caregivers can alleviate these pressures, leading to better job satisfaction for workers and improved care for residents, as highlighted in a recent article published in The Gerontologist journal. This adjustment helps create a healthier work environment and a higher standard of care.

Organizational Practices and Respect: Key to Caregiver Retention

Respect and appreciation in the workplace are crucial for retaining caregivers. Beyond just increasing salaries, creating a respectful and supportive work environment is essential. For example, when caregivers feel valued by their supervisors and part of a positive organizational culture, they are more likely to be satisfied with their jobs and less likely to leave. This positive work environment not only enhances caregiver morale but also improves the consistency and quality of care that older adults receive, as caregivers are more engaged and committed to their roles. Studies have shown that such an environment significantly reduces turnover intentions among staff.

Broader Implications and Calls for Policy Reform

The challenges faced by direct care workers in Baltimore are not isolated incidents but part of wider systemic issues that stem from current state and federal policies. These policies directly affect how long-term services and supports (LTSS) are funded, which in turn impacts the compensation and working conditions of caregivers. For example, insufficient funding levels can lead to lower wages and inadequate staffing ratios, contributing to job dissatisfaction and high turnover rates. Experts, like those from the Commonwealth Fund, advocate for policy reforms that could improve the financing mechanisms of LTSS, thereby enhancing both compensation and the overall work environment for direct care workers. Such reforms would not only benefit the workers but also improve the quality of care received by older adults.

Conclusion: Towards Comprehensive Solutions

To tackle the retention crisis effectively, a multifaceted approach is required—one that includes policy reform, better compensation, improved staffing ratios, and enhanced workplace respect. Addressing these issues will not only stabilize the workforce but also improve the quality of care provided to Baltimore’s aging population.

This research reveals that while the challenges are daunting, they are not insurmountable. With concerted effort and comprehensive strategies, it is possible to transform the working conditions for direct care workers and, by extension, the care quality for older adults in Baltimore and beyond.


  1. Maryland Regional Direct Services Collaborative. (2023). Report on Direct Care and Services Workers in Baltimore. Maryland Regional Direct Services Collaborative.
  2. The Gerontologist. (Various Dates). Studies on Long-Term Care and Staffing Issues. [Journal Article]. Oxford Academic. Available at: The Gerontologist
  3. Commonwealth Fund. (Various Dates). Research on Health Policy and Long-Term Care Financing. [Research Articles]. Available at: The Commonwealth Fund
  4. SmartAsset. (2024). Salary Needed to Live Comfortably in U.S. Cities. Available at: SmartAsset

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