Component 1 Introduction

Between November 2000 and January 2001, the Infrastructure Study Project completed a literature and key document review related to these three questions:

A.     To what extent are the appropriate and needed services for people with disabilities available?

B.      To what extent do key stakeholders perceive that they are receiving high quality services?

C.      To what extent are quality direct care providers being recruited and retained in New Mexico?

Based on the analysis of that information, as well as review of additional surveys, the Infrastructure Study Steering Committee, then identified this key evaluation question for the study as the question which would best enlarge the body of knowledge without redundancy and most effectively move New Mexico’s developmental disabilities system forward:

To what extent are Direct Support Staff being recruited, retained and supported to provide quality DD Waiver services to adults with developmental disabilities in New Mexico?          

The 2002 review focused on reviewing more recent information relevant to the key question.

The Infrastructure Study Project included review of key documents such as full accreditation reports of community providers on file at Long Term Services Division, Department of Health, Community System Quality Review findings, and related survey information collected in New Mexico.Information such as the “New Mexico Annual Social and Economic Indicators” provided a broader context for recruitment and retention issues.The Infrastructure Study Project also reviewed relevant national literature.

See Appendix 1A for a full report of the information reviewed by the Infrastructure Study.

Findings

The Infrastructure Study Project analyzed the information in Appendix 1A and, from that, identified findings critical to answering the key evaluation question for the study.

 

Text Box: “Current difficulties in assuring adequate direct support staff recruitment, retention and competence are widely reported as the single biggest barrier to the growth, sustainability, and quality of community services for people with developmental disabilities.” (Hewitt, et. al. 2001)Scope of the Problem

National

Many researchers and commentators in the developmental disabilities arena agree that direct support staff recruitment and retention are part of what Nerney (2001) characterizes as an “emerging catastrophe in long term care”.Although one problem may surpass another at a given point, “…recruitment and retention challenges are inextricably linked, so problems in one area put heavy pressure on the other…” (Larson, S.A. and Lakin, K.C., 1999). The last study to measure turnover nationally as conducted in 1992 and found direct support staff turnover ranging from 45% to 70%– supervisors also have a high turnover rate (Hewitt, A.and Lakin, K.C., 2001). Recent studies conducted in various states confirm that direct support staff turnover is still high (Hewitt, A. and Lakin, K.C, 2001; Clabby, R.T. and Heinlein, K.B. 2001).

The impact of higher turnover can result in “…low morale, absenteeism, …burnout [with]… existing [direct support staff] often work[ing] overtime shifts…[leading to] exhaustion, increased mistakes, [and] decreasing quality…” (Hewitt, A. and Lakin, K.C., 2001). Use of substitute staff can result in “quality deterioration” as the substitute staff may “…not always know the routines and the needs of the people receiving services nor how to provide supports …” (Hewitt, A. and Lakin, K.C., 2001).

Text Box: “The annualized cost of DSP turnover in the United States is astronomical.” There is also a high “human cost” to people served. (Hewitt, et. al. 2001)

Turnover also has great economic impact.Nerney (2001) reported that, “Annual financial and human resources lost to recruitment and training vary from$2,400 to $5,000 per new recruit.”In fact “…the costs ofproducing satisfactory assistance will more likely rise than decline as the desire for competence and continuity in staff meets the growing scarcity of people interested in providing personal assistance.”(O’Brien, J., 2001).

This recruitment and retention crisis also has a “human cost”.(Hewitt, A. and Lakin, K.C., 2001). “People living in a small residential setting are routinely expected to ‘get used to’ five or more new employees each year coming into their home, often providing the most intimate of personal care or other supportive aspects of their private lives” with less of a chance to build relationships, trust, mutual respect and independence (Hewitt, A. and Lakin, K.C., 2001).“The lack of reliable, quality staff brought on by current job conditions already places patients and disabled individuals at risk….” (Clabby, R.T. and Heinlein, K.B., 2001).

Many factors contribute to what Hewitt (2001) calls the growing “direct support workforce crisis”.

The majority (61%) of people with “mr/dd” live with family caretakers – 15% live with a spouse, 14% live in their own household, 10% live in supervised residential settings (Braddock, D., Hemp, R., Rizzolo, M.C., Parish, S. and Pomeranz, A., 2002). These family caretakers are aging (25% are over 60 years of age and 35% are aged 41-59) while people with developmental disabilities are living longer lives (Braddock, D., Hemp, R., Rizzolo, M.C., Parish, S. and Pomeranz, A., 2002). As these family

People with disabilities are living longer lives and a majority live with their families. A quarter of family caretakers are over 60 years old. (Braddock, et. al.2002) This means the number of direct support workers will have to increase “significantly” as people age. (Nerney,2001)

caretakers age and people with disabilities live longer, the number of direct support workers will have to increase significantly (Nerney, T., July 2001).

Text Box: The … “current pool of direct support workers [is] shrinking in dramatic fashion…”. (Nerney, 2001)

Most direct support staff members are “females…below the age of 39 …” (Hewitt, A. and Lakin, K.C., 2001). “The demographic pool [people between 20 and 44] from which caretakers are recruited is declining, the

need for more workers is steadily increasing”- these workers are also more culturally diverse (Hewitt, A. and Lakin, K.C., 2001).

            The recruitment pool is also shrinking because of competition. Competing jobs like retail outlets and fast food restaurants offer the same wages for less stress than direct support jobs (Clabby, R.T. and Heinlein, K.B., 2001). Compounding the problem of trying to provide wages attractive to new workers, if border states offer higher wages, they can attract workers away from a state with lower wages (Clabby, R.T. and Heinlein, K.B., 2001).With increasing health care costs, providers also have difficulty providing competitive benefits (Hewitt, A. and Lakin, K.C., 2001).

With deinstitutionalization, the people who live in supervised residential settings are now served in more service settings- these settings are smaller and more dispersed leading many staff to experience isolation, more responsibility, and less supervision (Hewitt, A. and Lakin, K.C., 2001).  The three top reasons that direct support staff leave their jobs are:co-worker problems, poor pay, and supervisor problems (Hewitt,

Text Box: Service settings are now smaller and more dispersed. Staff members have “expanded responsibilities and …increased isolation…” Pay and issues with co-workers and supervisors top the list of reasons staff leave. (Hewitt, et. al. 2001)

A. and Lakin, K.C., 2001).  It can also be a challenge to deliver training to these dispersed staff, especially when they work “around the clock”; another training issue is that the national “skill sets” developed in the “1996 Community Support Skill Standards” (Taylor, M., Bradley, V., and Warren, R., 1996)for direct support staff have not been uniformly implemented (Hewitt, A. and Lakin, K.C., 2001). As a final factor contributing to turnover, in the past, direct service has not been considered an occupation, which is honored, tracked, targeted by educators and other labor sources (Hewitt, A. and Lakin, K.C., 2001).

New Mexico

In the “2000 Community Review”, Linda Glenn identified “Stability of work force” as a major issue noting: “significant turnover in staff in all positions”. She cited as contributing factors: “low wages, inadequate training and supervisory support; the level of difficulty providing services to high need

Text Box: New Mexico’s Department of Health Long Term Services Division “2000 Community Review” listed “stability of the work force” as a “major issue” noting “significant turnover in staff in all positions.” (Glenn, 2000)

individuals; increasing demand on existing staff; and the high availability of less stressful jobs with equal or greater wages.” Problems found in this review were “…often attributed to the high staff turnover”. “Many residential and day providers reported at least a 40% or more direct care turnover.” “It was the assessment of the review team that many data elements in the Community Systems Review reflect this issue of staff stability”: overall service adequacy was below 50%; sufficiency of learning/working services dropped to 47%; ISP’s developed by appropriately constituted team were below 50%; and access to socially integrative activities was 62%.“Guardians and consumer concerns …centered on the constantly changing staff, not only in residential, but throughout the system” (Glenn, L.L., 2000).

Focus Group participants in the Somos Familia Study (2000) identified recruitment, training, and retention as a major problem and commented that low pay makes it difficult to recruit and retain qualified staff.

Text Box: New Mexico is 49th in per capita income and 3rd highest in unemployment.(Department of Labor, 2001)

 

 

One important factor to consider in relation to recruitment and retention is the economic environment.The New Mexico Department of Labor (2001) reports the following statistics. New Mexico is 49th in per

capita income ($22,203) and 3rd highest in unemployment.The counties

reporting the highest unemployment were: Luna (22.9%), Mora (15.4%), Hidalgo (10.6%), and Taos (10.5%). The counties reporting the lowest unemployment were: Los Alamos (1.9%), Union (2.7%), Santa Fe (2.7%), and Sierra (2.9%).The counties with the highest food stamp usage were: McKinley (20%), Socorro (19.2%), Socorro (19.2%), and Torrance (15.1%).The school districts with the highest drop out rates were: Dulce (30.6%), Santa Fe (12%), and Cuba (11.4%).

“The average turnover rate for direct care staff was 32.5%” with some providers as high as “82%”.ADDCP, 2000

Text Box: “The average turnover rate for direct care staff was 32.5%” with some providers as high as “82%”.ADDCP, 2000In 2000, the Association of Developmental Disability Community Providers (ADDCP) completed a survey which found that “The average turnover rate for direct care staff was 

32.3%.Albuquerque providers experienced the highest turnover rates with some providers reporting rates as high as 69%, 70% and 82%.Some rural communities reported rated as high as 54% and 62%.”In a separate study, the New Mexico Department of Health, Long Term Services Division (2001) reported these turnover rates by job type: 58% residential; 34% DD other; 29% Case Management – new hires outstripped staff lost except in residential where it held even.

In considering turnover and hiring of staff in New Mexico, it is important to also consider any changes in number of people being served.In its 2001 Annual Report, the New Mexico Department of Health Long Term Services Division reported that 316 additional people were served on DD Waiver while 29 less people served through State General Funds.The Research and Training Center on Community Living Institute on Community Integration (2001) reported that New Mexico served 104 additional people in ICFMR settings in 2000; and served 44 less people in nursing homes in that same year.

¢     Conclusions

Clearly, workforce stability is a major issue crucial to quality of services to individuals with developmental disabilities both nationally and in New Mexico.As the family caregivers age and the typical labor pool shrinks, this issue will grow larger. Fortunately, New Mexico can draw on a number of resources and strategies that already exist or have been suggested.

Develop A Comprehensive Workforce Development Plan For Direct Support Staff

Workforce stability is clearly a whole system problem – not just a provider problem (Hewitt, A. and Lakin, K.C., 2001). New Mexico can create a comprehensive workforce development plan for Direct Support Staff, which integrates the following strategies.

Related Strategies

Strategy 1.1: Promote And Assure Quality

*   Implement people choosing their direct support staff as a quality measure.

“…people…make choices about important life decisions, such as….support staff or provider (residential, work, and service coordination).” (NASDDS, 1999).

*   Infuse best practice into New Mexico. 

Choose best practices in recruitment and retention for application in New Mexico.For example, the National Alliance of Direct Support Professionals publishes specific recruitment and retention practice recommendations (Taylor, M., 2000). The IMPACT newsletter featuring recruitment, retention and training (Hewitt, A. and Larson, S.A.,1998) offers an example of how to use the media to publicize innovation.The President’s Committee on Mental Retardation’s (Jaskulski, T. and Ebenstien, W. [Eds.], 1998)publication on “the frontline workforce” offers another illustration.

*   Tailor efforts to regional characteristics.

New Mexico Department of Labor (NMDOL, 2000, 2001) information indicates wide variation in economic and cultural make-up across New Mexico counties.Match recruitment and retention efforts to regional characteristics.

*   Identify providers who are using techniques that work.

Use agency accreditation reports, Community Review results, as well as self-advocate and family comments to identify providers using innovative recruitment and retention practices (for example: recruitment bonuses, increased pay for longer job tenure, flexible hours to attend school, etc.).

*   Offer provider-to-provider mentorship.

Design a system of mentorship where providers with outstanding recruitment and retention practices mentor other providers with matching needs.

*   Collect continuous feedback from direct support staff, people with disabilities and their families on effectiveness of strategies implemented.

For the first time, in this study, direct support staff voices have expressed their point of view regarding their recruitment and retention.In the 2000 Community Review (Glenn, L.L., 2000), families and people with disabilities interviewed also expressed their concerns.Collect, analyze and implement recruitment and retention suggestions from those providing and receiving services to assure and continuously improve quality.

*   Continue study of the issue including impact of turnover on people served.

Collect wage and other recruitment and retention data – including information on salaries offered by bordering states (for example, in 2000, Colorado paid $8.95 an hour to direct support staff, Hewitt, A. and Lakin, K.C., 2001). Compare this information with economic indicators and other information.Examples of other recruitment and retention issues which could be studied include: number of part-time vs. full time positions, number of people served compared to number of positions, recruitment and retention statistics across different service models (including non-traditional models).

Strategy 1.2:Continue To Improve Compensation

In the 2000 Community Review, Glenn recommended that New Mexico “upgrade direct care salaries to a level which can assure market comparability to other health care and retail levels; provide a mechanism for automatic increases for all staff based on indices …; [and]prior to budgeting for 2002-2003, a true market study of salary and benefits needs should be undertaken to refine the automatic indexing elements, by position, job responsibility and locality…” and to basefuture budgets, waiver applications and HSD rate adjustments on this “for all positions”. There are wage increase models to consider from many other states (Braddock, D., Hemp, R., Parish, S. and Rizzolo, M., 2000; Hewitt, A. and Lakin, K.C., 2001). Any wage increase must consider not only base pay to new recruits but also pay increases for longer tenure employees (Hewitt, A. and Lakin, K.C., 2001).

As Larson and Lakin (1999) express, compensation must be seen more broadly than just wages: “Although much can be done to improve recruitment and retention with agencies and individual homes, little of it holds much promise without wage and benefit structures that provide direct support professionals with decent compensation for the important work they do. Compensation must be viewed more broadly than traditional wage and benefit packages.Providing flexible benefit packages … offering items such as child care or transportation…state legislatures need to…support significant alternative benefits, such as tuition credits for public college and university based on hours worked…and other direct benefits.The resources for adequate compensation must also derive in part from reforms that enhance productivity by reducing administrative and rule-dictated expenditures…”

Strategy 1.3: Explore Non-Traditional Service Models

Consider non-traditional service models emerging from the self-determination movement.

*   Support self-determination in recruitment and retention practices. 

For example, people with disabilities can hire and fire the people who support them.

*   Study and implement the self-directed service model.

This model offers more flexibility in who is recruited and how much they are paid – people and families accessing this model should receive recruitment and retention support (Hewitt, A. and Lakin, K.C., 2001). 

*   Encourage non-traditional partnership relationships mutually beneficial to people served as well as to direct support staff.

For example, Nerney describes“asset accounts (matched savings accounts) for direct service staff and people with disabilities to use [for] home, …as well as microenterprise development [which can be ‘…an alternative to employment…’] and higher education” (Nerney, T., July, 2001).

*   Use “imaginative job descriptions…to allow for direct support workers [chosen “by the person with a disability”] to [partner] in business and commerce with individuals with disabilities…” (Nerney, T., July 2001).

*   Support people accessing non-traditional models with “brokering” (“a variety of functions that assist people to deal with the transaction costs of necessary assistance…[such as] gathering a circle for support, …selecting and organizing suitable service providers…” (O’Brien, J., 2001).

Strategy 1.4: Tap Non-Traditional Pools of Potential Employees

*   Recruit individuals with disabilities as employees and adapt the workplace to meet their needs.Also recruit employees from families and friends (Nerney, T., July 2001; Nerney, T., October 2001) providing any needed supports and safeguards to ensure choices are protected.As “…70% of people with significant disabilities are unemployed…” (Nerney, T., July 2001) this is an employment resource.

*   Educate pre-service educators and “workforce development specialists” about direct support as a career and encouragement to school-to-work, welfare-to-work, technical colleges and other formal programs” include direct service in “menus of occupations” (Hewitt, A. and Lakin, K.C., 2001).

*   Partner with One Stop Career Centers and the Division of Vocational Rehabilitation for recruitment from non-traditional populations such as TANF recipients (NMONE Training Project, 2001).

Strategy 1.5: Network And Leverage Resources (Including National Networking)

*   Partner with self-determination efforts to seek non-traditional solutions to recruitment and retention such as individuals hiring and firing their own staff.

*   Continue collaborative provider partnerships to assess (ADDCP, 2001)and address recruitment and retention issues as has been done in other states.

*   Encourage providers to join Job Service employer councils – for networking, technical assistance, recruitment, and to promote jobs for people with disabilities.

*   Encourage New Mexico Department of Labor to track labor statistics regarding the new “Direct Support Specialist Occupation” (NADSP, 2002; Hewitt, A. and Lakin, K.C., 2001) and to assist with developing a workforce development plan for Direct Support Staff.

*   Make sure provider branches are listed in DOL employer listings.

Strategy 1.6: Recognize Direct Support Staff And Increase Career Opportunities

*   Increase public awareness and appreciation of Direct Support Staff (Hewitt, A. and Lakin, K.C., 2001).

*   Support growth in New Mexico of the National Alliance for Direct Support Professionals, which includes a Code of Ethics and innovations for recruitment and retention.

*   Create career paths for direct support staff and opportunities to earn college credit.

*   Publicize the Direct Support Specialist Occupation and other apprenticeship options.

*   Tie future levels of training competencies in New Mexico to the 1996 Community Support Skill Standards (Taylor, M., Bradley, V., and Warren, R., 1996)

*   Increase access to training for shift workers through distance education and other methods (Hewitt, A. and Lakin, K.C., 2001) such as mentoring.


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