Cover: An Evaluation of a Multisite, Health Systems–Based Direct Care Worker Retention Program

An Evaluation of a Multisite, Health Systems–Based Direct Care Worker Retention Program

Key Findings and Recommendations

Published Sep 6, 2022

by Julia Rollison, Julia Bandini, Katie Feistel, Allyson D. Gittens, Megan Key, Isabelle González, Weilong Kong, Teague Ruder, Jason Michel Etchegaray

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Research Questions

  1. Did retention rates improve during or after THRIVE implementation?
  2. Can THRIVE break even or generate a positive ROI so that it is financially sustainable without philanthropic support?
  3. What factors were associated with retention?
  4. What are the strengths of the THRIVE intervention, and what are areas for improvement?
  5. What lessons learned would other sites need to leverage when implementing a similar intervention in the future?

The U.S. direct care workforce employs nearly 4.6 million people and represents one of the fastest growing occupations in the United States. Direct care workers, or "caregivers," include nursing assistants, home care workers, and residential care aides, all of whom provide basic care to older adults and individuals with disabilities in various health care settings.

Despite a growing need for caregivers, supply has not kept up with demand due to high turnover and low wages. In addition, caregivers often face high levels of workplace stress, limited training and growth opportunities, and personal stressors. Ranging from 35 to 90 percent, depending on the health care setting, the turnover rates of direct care workers pose a major challenge for health systems, as well as care recipients and workers themselves.

In 2019, the Ralph C. Wilson Jr. Foundation funded three health systems to support the implementation of a new program: Transformational Healthcare Readiness through Innovative Vocational Education (THRIVE). This 12-month program was designed to help address barriers that entry-level caregivers experience and reduce turnover through a comprehensive risk assessment, training, and one-on-one coaching. Researchers from RAND conducted a process and outcome evaluation to determine whether THRIVE was meeting its goals of improving retention and achieving a positive return on investment (ROI). They also examined potential areas for program improvement.

Key Findings

  • In comparison to a baseline year, retention rates did not improve across sites during Years 1 or 2 of program implementation
  • The financial return on investment was negative: for every dollar invested, the program lost $1.09 in Year 1 and $1.11 in Year 2.
  • Caregivers in the lowest pay category and those who identified as Black were more likely to have their employment terminated than those in highest pay category or those who identified as White.
  • The program was implemented differently than originally designed due to staffing shortages, local variations, and COVID-19.
  • Participating caregivers indicated an overall indifference to and neutral perspectives on the program.


  • Program leaders should clearly articulate program goals to different stakeholders in the organization (i.e., leadership, managers, and caregivers) before, and during, implementation.
  • Planners should increase diversity among those developing and delivering the program.
  • Staff who implement the program should be mindful of the need for clear documentation of processes and program data.
  • Future programs should prepare early, obtain organization support, and clarify roles and responsibilities among a diverse program staff team.
  • Future evaluations should apply evaluability assessments to inform the evaluation design; incorporate a broader range of respondents, such as individuals who are no longer in the program; and focus on equity, particularly as it relates to caregiver outcomes.

Research conducted by

The research described in this report was sponsored by Ralph C. Wilson Jr. Foundation conducted in the Social and Behavioral Policy Program within RAND Social and Economic Well-Being.

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