Introduction and Purpose

In November 2000, the Community Support Alliance at the Center for Development and Disability entered into a contract (MOU 01-647.10.89.008) with the New Mexico Developmental Disabilities Planning Council to conduct a statewide comprehensive Infrastructure Study for the purpose of examining and making recommendations regarding crucial issues affecting the stability of New Mexico’s service system infrastructure and quality of services. The study initially focused on 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?

The first step in the study was to complete a review of relevant literature, key documents as well as other surveys completed in New Mexico related to those three questions. The analysis of that review was presented to the Infrastructure Steering Committee which was charged with identifying and refining a key evaluation question for the Infrastructure Study which would best enlarge the body of knowledge without redundancy and most effectively move New Mexico’s developmental disabilities system forward. The Infrastructure Steering Committee chose this key question for the final purpose and focus of he Infrastructure Study:

This Executive Summary outlines the methods used to study the key question and summarizes findings and overall recommendations. The remainder of the report of the study is organized into three components that give detailed introductions, qualitative and quantitative research methodology, findings and conclusions for each type of study method undertaken.
 

Methodology

The Infrastructure Study Project studied the key question using these three methods: literature and key document review; qualitative research through selected focus groups with people with developmental disabilities and interviews with key stakeholders; and quantitative research through a survey to direct support staff. The selected focus groups were completed both to inform survey question development and to enlarge the perspective on the focus of study.

Triangulation of information was used at two levels to ensure the thoroughness of the qualitative and quantitative information gathered. The first level included triangulation of respondent sources (Figure 1); the second level included triangulation of data collection methods (Figure 2).
 
 
 
 
 
 

Figure 1: Triangulation of Respondent Sources

            People with Developmental Disabilities

Key Stakeholders                                 Direct Support Staff

Figure 2: Triangulation of Data Collection Methods

                        Focus Group Interviews

Individual Interviews                             Written Survey

Findings

The Growing Crisis Has High Costs To Quality

Researchers agree that direct support staff recruitment and retention are linked together in a national crisis likely to worsen as the demographic pool from which direct support workers are typically recruited declines, the family caregivers who care for 60% of individuals with developmental disabilities age, and individuals with disabilities live longer lives, waiting lists grow, and services expand. The recruitment pool is also shrinking from competition from higher paying, less stressful positions. In fact, both nationally and in New Mexico, stability of the workforce is identified as a major barrier to quality of services. Direct support worker turnover costs are "astronomical" both financially and emotionally to the people being served (Hewitt, A. and Lakin, K.C., 2001; Braddock, D., Hemp, R., Rizzolo, M.C., Parish, S. and Pomeranz, A., 2002; Clabby, R.T. and Heinlein, K.B., 2001; Nerney, T., July 2001; Glenn, L.L., 2000; Somos Familia Study, 2000; Component 2 - see Component 1 for detailed quotes and comments on literature cited in this Executive Summary). Focus group comments, analyzed in Component 2, reveal that 89% of self-advocates responding "feel sad when their direct support staff person quits or leaves".
 

New Mexico Compares With National Turnover Trends

The last national study of turnover found direct support staff turnover ranging from 45% to 70%. One recent study in New Mexico found turnover at 32.5% in a sampling of providers with some reporting as high as 82%. Another reported these turnover rates by job type: 58% residential; 34% DD other; 29% Case Management. Another review received reports of 40% and more direct support staff turnover in residential and day service settings (Hewitt, A. and Lakin, K.C., 2001; Association of Developmental Disability Community Providers, 2000; Department of Health Long Term Services Division, 2001; Glenn, L.L., 2000).

Service Delivery Model Changes Have An Impact

With deinstitutionalization nationally and the complete closure of institutions in New Mexico, people with disabilities are being served in smaller settings that are further apart. Staff members have "expanded responsibilities and…increased isolation" with less supervision; however some new models such as self-directed services promise, if given needed supports, to offer new recruitment solutions. Key stakeholders noted a need both for systemic and agency infrastructure changes to address recruitment and retention issues.

State And County Economic Factors Play A Part

New Mexico is 49^th in per capita income and 3^rd highest in unemployment. There are large variations in factors such as unemployment and high school dropout rates across different counties in New Mexico.

How Direct Support Staff Find Their Jobs

Nearly 60% of direct care staff responding to the survey analyzed in Component 3 heard about their jobs from friends or relatives.

Four Top Reasons Direct Support Staff Took the Job

Respondents to the survey analyzed in Component 3 rated these reasons as very important for selecting their job: "It was a job I knew I could do" (72%); "I wanted to learn more about working with people with disabilities" (65%); "The agency has a good reputation" (65%); and "The job fits my schedule" (50%).

Three Top Reasons Direct Support Staff Leave Jobs

National research reports that the three top reasons that direct support staff leave their jobs are: co-worker problems, poor pay, and supervisor problems. A related problem is that direct service has not been considered an occupation, which is honored, tracked, targeted by educators and other labor sources. New Mexico has reported these contributing factors affecting workforce stability, "low wages, inadequate training and supervisory support; the level of difficulty providing services to high need individuals; increasing demand on existing staff; and the high availability of less stressful jobs with equal or greater wages."
 

A Split Opinion On Competition

As referenced earlier, national researchers and the 2000 New Mexico Community Review identify competition from less stressful jobs as contributing to turnover. A majority of Key Stakeholders interviewed agreed. However, when asked, "If you were to decide to look for another job in your community, how many other job opportunities are there?" just over eighty percent (83%) said that there were "no", "not many" or "some" "job opportunities".

Initial Job Information Is Sufficient and Accurate

Direct support staff respondents felt that provider agencies give them sufficient and accurate information during the recruitment process about the nature of the challenging job they are about to enter.

Competency Based Training Earns High Marks

Survey respondents rated the competency-based courses mandated by Long Term Services Division highly and most felt the courses are offered at the right point in time.

New Mexico Educational Levels Are Lower

National research finds that most direct support staff have "…at least some college with …a third having college degrees". Nearly three-quarters of respondents to the survey analyzed in Component 3 had High School or GEDs as their highest educational degree.

Working Conditions and Compensation Contribute

Key stakeholders interviewed commented that working conditions in many settings are difficult and highly stressful with high quality expectations from the state. A growing number of people served who have very complex needs can make working conditions more demanding. Key Stakeholder interviews analyzed in Component 2 report that "Direct support staff are expected to perform professional work quality with non-professional wages and benefits" and urge the system to seek legislative funding for a significant wage and benefits increase. Over a third of direct support staff survey respondents who wrote comments indicated that wage increases were needed. National researchers suggest "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." Some New Mexico providers have addressed this broader view with new techniques that have positively impacted retention such as flexible hours, benefit packages, compensation, administrative support, communication, and on-the job training.
 

Recommendations and Strategies

The Infrastructure Study offers the following recommendations to address key findings.

Related Strategies:

Strategy 1.1: Promote And Assure Quality

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

   Infuse best practice into New Mexico.

   Tailor efforts to regional characteristics.

   Identify providers who are using techniques that work.

   Offer provider-to-provider mentorship.

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

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

Strategy 1.2: Continue To Improve Compensation

   Complete "a true market study of salary and benefits needs … to refine the automatic indexing elements, by position, job responsibility and locality…" and base future budgets, waiver applications and HSD rate adjustments on this "for all positions".

   Access wage increase models available from many other states.

   Consider not only increasing base pay to new recruits but also pay increases for longer tenure employees.

   View compensation more broadly than just wages and benefits to include such as flexible benefit packages, tuition credits, and flexible schedules.

Strategy 1.3: Explore Non-Traditional Service Models

   Support self-determination in recruitment and retention practices.

   Study and implement the self-directed service model that 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.

   Encourage non-traditional partnership relationships, such as asset accounts and business ventures mutually beneficial to people served as well as to direct support staff. ".

   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…")

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, providing any needed supports and safeguards.

   Educate pre-service educators and "workforce development specialists" about direct support as a career and encourage school-to-work, welfare-to-work, technical colleges and other formal programs" to include direct service in "menus of occupations".

   Partner with One Stop Career Centers and the Division of Vocational Rehabilitation for recruitment from non-traditional populations such as TANF recipients.

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 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" 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.

   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.

   Increase access to training for shift workers through distance education and other methods such as mentoring.

Strategy 1.7: Develop A Plan To Market The Direct Support Staff Position To Attract Long-Term Employees And Increase Public Awareness About The Field Of Developmental Disabilities.

Recommendation 2: Develop Marketing and Recruiting Strategies Tailored To Research Findings.

Related Strategies:

Strategy 2.1: Incorporate "It’s A Job You Can Do" And "An Opportunity To Learn About People With Disabilities" Into Marketing

Strategy 2.2: Share Information About The Agency’s Reputation

Strategy 2.3: Focus Recruiting Efforts On Powerful "Natural Networks" Of Friends, Relatives, And Other Informal Contacts Of Current Direct Care Staff.

Recommendation 3:Analyze and Improve Direct Support Staff Working Conditions

Related Strategies:

Strategy 3.1: Collect Job Analysis Information About Direct Support Staff Actual Duties And Responsibilities

Strategy 3.2: Compare Job Analysis Results To Direct Support Staff Required Qualifications, Infrastructure Supports (Such As Mentoring, Supervision), And Required Outcomes

Strategy 3.3: Field-Test Innovative Ideas To Reduce Stress And Improve Working Conditions (Such As Flexible Hours, Recognition, Wellness Programs, Effective Communication)

Strategy 3.4: Assure that staff are adequately trained and supervised to safely and competently support individuals with great challenges.