Direct Care Workers


Direct care workers are known by many names, including direct service worker, direct support worker, direct support professional, paraprofessional, and aide. Individuals in these roles typically have a high school diploma, GED, or a college certificate. The usual preparation for their jobs involves a very brief orientation or on-the-job training. With little formal preparation and without much supervision and support, they are often asked to provide care to individuals and families facing complex and serious problems.

These workers are common in at least four major sectors within healthcare: aging and senior services; intellectual and developmental disabilities services; physical disabilities services; and behavioral health. Community Health Workers can be considered yet another type of direct care worker. Since direct care workers comprise the overwhelming majority of the workforce in the non-behavioral health sectors listed above, there has been more attention to this segment of the workforce in those sectors. Behavioral health can and has drawn on advancements regarding direct care workers in these other fields.

Direct Care Workers in Behavioral Health

The national Action Plan for Behavioral Health Workforce Development (Annapolis Coalition on the Behavioral Health Workforce, 2007) concluded that direct care workers constituted the single largest segment of the mental health workforce; larger than any single profession. While they play a vital role in inpatient, residential and ambulatory treatment programs, there is no professional association or advocacy organization that promotes their interests or guides their training and development. Initial orientation and training for their roles tends to be minimal; supervision of their work is usually sparse; and pay is often at or near minimum wage with few opportunities for wage increases or career advancement. There are exceptions to these patterns in some state-operated systems of care, which may offer these workers a living wage and advancement opportunities.

Peer specialists in mental health and recovery coaches in the field of addictions are often thought of as direct care workers. However, given their lived experience and specialized roles, peer specialists and recovery coaches are typically considered to be unique segments of the behavioral health workforce. Anecdotal reports often suggest that a higher than average percentage of direct care workers do have lived experience of mental health or substance use conditions, whether or not they identify to others as being in recovery. The mental health of direct care workers and the impact of stress on their health are special concerns.

Best Practices with Direct Care Workers in Mental Health

The Hitachi Foundation funded an initiative to identify organizations in the behavioral health field that exhibited best practices with direct care workers. The Behavioral Health Pacesetter Award in Support of the Direct Care Workforce identified seven exemplary organizations that each accomplished three goals:

  1. Improved work-life balance, skills and economic advancement among direct care employees
  2. Improved client outcomes based on the organization’s delivery of high-quality services and supports
  3. Strengthened business performance and bottom line results.

The best practices identified within these programs included the following:

  • Used evidence-based practices, and monitored and maintained adherence to practice fidelity.
  • Actively supported the educational and career development aspirations of front-line workers.
  • Provided competitive wages, benefits and other incentives to employees.
  • Developed and maintained partnerships with academic and research institutions that actively promoted training and other involvement of direct care workers.
  • Provided highly individualized and supportive supervision to staff on a frequent, regular basis.

More information is available here.


Community Mental Health Journal

This journal publishes articles frequently on this segment of the workforce. Recent articles have focused on direct care worker training, turnover, roles in group homes, children’s mental health services, rural healthcare, and advocacy activities.

PHI: Quality Care through Quality Jobs

PHI is a prominent policy and advocacy organization focused on the direct care workforce. While its interests center on the long-term care workforce (home care and institutional care), the work of PHI often has considerable relevance to behavioral health.  

Competencies and Competency Training Resources

Direct Care Workers and Older Adults

Community Health Workers

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