Community-based services for people with I/DD have been underfunded since the inception of deinstitutionalization back in the 1960s. People with I/DD were removed from the institutions into communities with no real plan, funding, or infrastructure to ensure their successful transition from the institution to the community. The Direct Service Professionals (DSPs) hired to help them were left to fend for themselves with little training or direction.
The result of poor reimbursement for community-based services for people with I/DD is a staffing shortage of Direct Service Professionals (DSPs) to provide this population with the training and support they need. Without enough staff, the people with I/DD who need support and training go unsupported and untrained. When working short-staffed for an extended period of time, the staff can become burned out and may choose to leave.
The largest funding stream for LTSS for people with I/DD are Medicaid Home and Community Based Services (HCBS) 1915(c) waivers. “With DSP work force challenges existing for over 30 years, these challenges are more than a crisis – they are a systemic failure resulting from a misalignment of expectations for increased service delivery without sufficient funding increases.” (INDIANA ARC).
I recently had the opportunity to interview Laurie Callaghan, CIO of Barber National Institute, a prominent nonprofit organization in Erie, Pennsylvania whose purpose is to meet the needs of children and adults with autism, intellectual disabilities, or behavioral health challenges and their families. I asked Laurie what were the major issues concerning agencies who serve people with I/DD? Laurie responded,
“The biggest topic in IDD right now is the insufficient reimbursement rates in IDD (in Pennsylvania and probably elsewhere). In PA, rates were adjusted this year but were based on outdated expense assumptions that barely allow providers to break even this year and the rates will not even be considered for adjustments for another 2-3 years. This contributes to the staff shortage and our ability to attract staff as we struggle to compete with wage rates. “
Direct service professionals provide people with I/DD training and support to live an as independent and self-directed life as possible in and among the community. These supports include activities of daily living such as house cleaning, cooking and personal hygiene; budgeting and money management; purchasing and shopping; socialization skills; transportation skills and much more. DSPs are the backbone of community-based services.
The direct support workforce is one of the fastest growing in America due to population growth, the increased life expectancy among persons with disabilities, the aging of family caregivers, and the mandated movement from institutional to community-based services. (The Direct Support Professional Workforce Crisis: Challenges, State Approaches, and Opportunities for the state of Georgia 10/4/2019). I worked as a direct support professional to people with I/DD in my early career. I can tell you that what pulls people to this career field is a genuine desire to care for others as well as a desire to facilitate others to help themselves and live as independently as possible. It is the hardest job I ever loved.
The newest National Core Indicators (NCI) Staff Stability Survey, with data from 2018, is now available, finding the national average yearly turnover rate for Direct Support Professionals (DSPs) is 51.3 percent. According to ANCOR (an advocacy group for community providers) the reasons DSPs are leaving their jobs is greater than poor wages. In my research of many other sources, I learned that DSPs are leaving due to lack of appreciation from management, poor benefits, lack of career path, and poor training and poor onboarding in an increasingly complex field. The responsibilities of DSPs are great, and people who work in this field are committed to the people they serve.
The Council on Quality and Leadership reports that
There are a number of approaches states are taking to address this crisis. States are forming in-state partnerships to collaborate with state workforce agencies, trade associations, and educational institutions. Legislatures are advocating for a standard occupational classification for DSPs to improve workforce data collection. Wages and benefits are being evaluated and Medicaid reimbursement rate changes, including cost of living adjustments, wage pass throughs, and value-based payments are being implemented. Competency-based training and affiliated credentialing has been found to positively impact staff retention and outcomes for people receiving support. Among many state-level efforts, comprehensive interventions to increase the recruitment and retention of DSPs are being undertaken by Tennessee, Ohio, and New York.
Below is a list of some of the things Barber reports that have improved DSP retention and have helped attract DSP applicants:
- PA DSP Credentialing: Pennsylvania has a DSP credentialing program such as the one available through the Pennsylvania Highlands Community College has helped with staff retention and attracting new hires to Barber because it provides a career path which is so important to employees. The DSP credentials are rewarded with pay increases which may not be funded by the specific program the DSP works in but rather by a different program with a greater fund balance.
- Sign On Bonus: Barber has a sign on bonus for DSPs which has helped with pulling in new applicants. Most agencies in Pennsylvania that serve clients with I/DD are offering sign on bonuses, so Barber had to do the same to stay competitive.
- Grant dollars: Although grant dollars are not ideal for hourly rate increases (because grants run out), Barber has used them in the past for bonus or incentive payments for DSPs.
- Use of students: Barber has long had many college students work as DSPs part time, which has helped fulfill their staffing needs. They are now reaching out to high schools as well as, with DSP certification, this is a valid career path.
- Weekly orientation Training: Barber hosts weekly orientation training so that new hires can be trained and put into the workforce as soon as possible.
Another idea Laurie and I spoke about, but Barber has not tried yet is asking the families to volunteer (where they can) to do such things as drive their family members to medical appointments. This helps address the staff shortages by decreasing the need for the staff to transport the clients to these appointments.
The Barber Institute is just an example of the many I/DD agencies in Pennsylvania and across the country that struggle to fill its DSP positions. With fast food chains being able to pay up to $15.00 an hour, non-profit agencies who serve people with I/DD find themselves competing with fast food chains for staff and the agencies just can’t pay as well. All of these initiatives and ideas are solid and can help address the problem but with turnover rates continuing to be 45% to 51.3% what we really need is for our legislators to act and increase the Medicaid Long Term Services and Supports (LTSS) and Home and Community Based Services (HCBS) waiver reimbursement rates so we can elevate the DSP role and pay them more closely to what they are worth. Direct Service Professionals are the linchpin of the services that allow people with I/DD to live in and among the community. They deserve to be paid a competitive wage reflective of the responsibility they have and the training they require.
If you would like more information about the Barber National Institute and find out about what you can do to help in their mission, please visit their website at Barberinstitute.org.
