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Recruitment, Assessment, and Retention in the Direct Care Workforce for Individuals With Criminal Records: A Comprehensive Model Approach

Executive Summary
Download the full report
Date Published
September 13, 2021


Demographic shifts are creating a heightened need for direct care workers. The U.S. Bureau of Labor Statistics predicts home health aides and personal care aides will continue to be among the fastest-growing occupations. Researchers estimate there will be over 150,000 paid direct care positions unfilled in the next decade and a shortage of almost 350,000 direct care workers in the United States by 2040 (Osterman 2017). Anticipated worker shortages have prompted national conversations about the potential benefits and considerations involved in hiring individuals with criminal records for the direct care workforce. Linking certain individuals with conviction records to entry-level jobs in this industry could help fill critical shortages, connect this population to employment and potential career paths, and ultimately contribute to successful reintegration and increased public safety. The goal of this white paper is to identify strategies for connecting individuals with criminal records who do not pose an unreasonable risk to public safety to long-term employment in the rapidly growing health care sector.

This paper has five key objectives:

  • Describe the heightened demand for workers in the health care industry and opportunities for hiring qualified workers with criminal records.
  • Review employer concerns, barriers to employment, desistance policy goals, and strategies for incorporating desistance into criminal background check policies.
  • Document existing recruitment and retention challenges in the health care sector more broadly, along with additional challenges that individuals with criminal records may face.
  • Summarize existing estimates on individuals with criminal records in the health care industry and identify where this group drops out in the background check process.
  • Provide strategies to improve recruitment, assessment, and retention of individuals with criminal records in direct care work, including the potential advantages of a collaborative and comprehensive model.

Key Takeaways

  • Many individuals with criminal records do not pose an unreasonable risk to the safety of health care staff, patients, or residents. Standardizing criminal record assessments (including the use of accurate and updated information), combined with the selective use of evidence of rehabilitation (based on strong signals of desistance) can help identify this group.
  • Several factors influence recruitment and retention of direct care workers, including low pay, irregular hours, physically demanding tasks, injuries on the job, low levels of perceived respect and job satisfaction, and barriers to occupational mobility. A key protective factor for retention is a strong commitment to patients and residents.
  • There appears to be a sizable opportunity for recruiting individuals with criminal records for direct care work. In addition to the importance of increasing employment numbers through recruitment, assessment, and long-term retention, a case study in New York also points to the need to secure applicants for direct care work who successfully pass the criminal background check.
  • Sixteen policy ideas were identified to improve recruitment, assessments, and retention. Two large-scale and popular employment strategies for individuals with criminal records, Ban the Box and record concealment (i.e., sealing and expungement), are anticipated to have limited effects in the direct care workforce and are excluded from the recommended policies here.

Summary of Recommended Policy Strategies

The table below summarizes the major policy ideas identified for improving recruitment, assessment, and retention practices, along with potential stakeholders that could lead each effort. Prior to implementing these recommendations, employers and policymakers should conduct needs assessments to identify which strategies may be the most effective. This involves collecting and retaining data on worker shortages, applicants and employees with and without criminal records, assessment decisions, employment outcomes (including reviews, promotions, disciplinary reports, and dismissals), and challenges experienced by the direct care workforce.

Summary of Recommended Policy Strategies
Strategy Lead Roles Recruitment Assessment Retention
Launch marketing campaigns to reduce stigma and promote direct care work Policymakers, employers, researchers X    
Expand existing workforce development programs and develop partnerships between employers and community organizations to create referral pipelines Policymakers, employers, community organizations X    
Recruit formerly incarcerated hospice workers and facilitate a pipeline partnership Policymakers, employers X    
Consider other human services collaborations to incentivize employment Policymakers X    
Promote word-of-mouth referral systems among employees with criminal records Employers, employees X    
Review existing resources and best practices for conducting criminal background checks Employers   X  
Train decision-makers on cleaning and interpreting criminal records Policymakers, employers   X  
Share criminal records with job applicants to verify accuracy and create a standardized process to encourage formal contestations Employers   X  
Avoid “blanket bans” (which disqualify everyone with a criminal record) and disqualifying conviction lists; instead, consider using comprehensive and individualized assessments Employers   X  
Streamline decision processes and enable people to work in temporarily supervised positions before final determination Employers   X  
Identify strong potential signals of desistance and build evidence of rehabilitation into decision processes Employers, researchers   X  
Promote, use, and test existing employer incentives (tax credits and the Federal Bonding Program) Policymakers, employers, community organizations, researchers   X  
Provide ongoing training, career guidance, and mentorship to health care employees with criminal records Policymakers, employers, community organizations     X
Provide access to reentry support services, such as treatment programs and transportation Policymakers, employers, community organizations     X
Expand job responsibilities and inclusion in medical teams Policymakers, employers     X
Implement a comprehensive and collaborative health care employment improvement model Policymakers, employers, community organizations, funders, researchers X X X

Note: “Policymakers” could refer to various entities at the national or local level, including organizations concerned about the direct care workforce shortage, government officials and agencies, and direct care workforce committees. The term “community organizations” refers to groups that can serve as intermediaries.

Although any of the strategies could be implemented in isolation or in combination, the final row points to a comprehensive health care employment improvement model to help alleviate the longer-term health care shortage. Most of the proposed strategies could be collaborative, but a key feature of a comprehensive model is that policies are implemented across all three categories (recruitment, assessment, and retention).

Policymakers, employers, community organizations, and researchers can serve as potential stakeholders across the policy strategies, and could each take a leadership role in promoting a collaborative and comprehensive strategy. Although three existing models — the Baltimore Population Health Workforce Collaborative (BPHWC), Safer Demand Skills Collaborative (SDSC), and Johns Hopkins Health System — have not yet been rigorously evaluated, they provide a framework for envisioning how coordinated efforts might operate. Each involves multiple stakeholders, aims to develop a pipeline of employee referrals for identified employers, and provides ongoing career guidance, mentorship, and support services after people secure jobs to increase retention. In addition to recruitment and retention components, the SDSC and Johns Hopkins models also include assessment strategies, making them both collaborative and comprehensive. Although the SDSC is led by a community organization[1] and the Johns Hopkins approach is employer-initiated, the scope and goals of the two programs are similar in design. The BPHWC does not appear to take an active role in assessment interventions, but it is an example of a policymaker-led collaborative model.

Future Research

The full white paper identifies four research agenda items to strengthen evidence in this area:

(1) Gauge interest in direct care work and recruitment challenges

Discussions with individuals with criminal records and community-based organizations could help generate an estimate of direct care positions that might be filled by recruiting this population and potential “chilling effects” of routine criminal background checks in the health care sector.

(2) Examine employer motivations and expand workplace evidence

Researchers could collect data from employers in the health care industry on their perceptions of prospective employees with criminal records, whether they screen people out informally (e.g., informal inquiries before the background check) or discourage this group from continuing the application process, and their feedback on tax credits and the Federal Bonding Program as incentives to hire this population. Data sharing agreements with researchers could also contribute to further developing direct care workplace evidence in several areas, including how to best incorporate evidence of rehabilitation into decisions, developing assessments that provide insight into potential workplace crimes, and more comprehensive evaluations of job performance.

(3) Explore retention rates and reasons

People with criminal records who are currently in entry-level or advanced direct care positions, along with those who left the direct care workforce, could provide insight into perceptions of job satisfaction, retention challenges, and best practices.

(4) Test the effectiveness of health care employment models

Building an empirical evidence base using randomized controlled trials is a key next step in this area. Research efforts could include local evaluations involving partnerships between employers, community organizations, and independent researchers; coordinated state-level evaluations through direct care workforce committees; and federal initiatives designed to support, implement, and evaluate multisite programs.


With hundreds of thousands of unfilled direct care jobs predicted in the next two decades (Osterman 2017), implementing select strategies can be a useful starting point. A piecemeal strategy may be the best approach for some jurisdictions, such as those able to identify specific priority intervention areas through needs assessments. Implementing strategies separately can also enable researchers to build a more rigorous evidence base that can help inform which components would be the most effective in a comprehensive model. However, this approach may not be enough to make a sizable impact in the long run. Health care employment improvement models that are both collaborative and comprehensive require strong partnerships, and engagement in all three key strategic components — recruitment, assessment, and retention efforts — could require substantial resources and time. As a long-term strategy, comprehensive models have the advantage of systematically addressing multiple parts of the process in a coordinated fashion. This framework has the potential to shift the way policymakers, employers, and community-based organizations envision and implement strategies to reduce shortages in the direct care workforce and employ individuals with criminal records.

Date Published: September 13, 2021