The Crisis
The demand for Direct Support Professionals continues to increase, as people with intellectual disability live longer and as members of the Baby Boomer generation enter the years in which the need for services and supports are increasingly likely. The supply of Direct Support Professionals is not able to keep up with this increased demand. In fact, the President’s Committee on People with Intellectual Disabilities (2018) describes the current situation as a workforce crisis. Employee turnover rates within the intellectual disability field are currently in the range of 40% per year, and roughly 20% of all Direct Support Professional positions are vacant (Spreat, 2019a). Historically, these values fluctuate, becoming worse when the economy improves and other jobs become available. Yet even under the most challenging economic conditions, the rates of turnover and open positions have remained unacceptably high.
High turnover rates and percentages of open positions impact other areas. Overtime costs are excessive because provider agencies must ensure appropriate levels of services and support. Given the needs of the individuals supported, providers cannot safely work short-staffed. In addition to negative budgetary effects, excessive overtime threatens the quality of services and supports. Staff who work overtime are often tired and sometimes they are assigned to work with consumers with whom they are unfamiliar and do not have a therapeutic relationship, which often form the basis of quality services and supports. Perhaps an even greater threat is that in face of high employee turnover and vacancy rates, employers tend to become less selective in hiring Direct Support Professionals.
The Cause
The imbalance between the supply and demand of Direct Support Professionals suggests a causal factor (Pittenger, 2017). Economists admonish that when prices (i.e., the costs of Direct Support Professionals) are in any way constrained, it is likely that shortages will follow. If Direct Support Professional pay is somehow unable to fluctuate in response to demand, there will be shortages of Direct Support Professionals. The University of Minnesota Center for Integration Studies (Larson, Lakin, & Bruininks, 1998) has demonstrated that the cause of turnover among Direct Support Professionals is low pay. This is an empirical demonstration of the negative impact of price controls.
Direct Support Professional wages are indeed constrained. Most of an intellectual disability provider agency’s budget is allocated to the costs of Direct Support Professionals. Figures as high as 70-80% are reported. Yet, unlike most other businesses, provider agencies cannot simply raise their prices in order to pay their Direct Support Professionals a living wage. Nor can they raise taxes like school boards. They have no control over their prices because prices in the intellectual disability field are typically set by the purchaser of the services – usually governmental agencies. Government entities do not directly constrain Direct Support Professional wages, but they limit the revenue potential for provider agencies, and this limitation ultimately ensures poor wages for Direct Support Professionals.
As a result of government fixed prices, the sustainability of intellectual disability provider agencies is often in question. For example, Spreat (2019b) reported that in each of five studied years, approximately 1/3 of all providers had expenses that exceeded revenues. He also reported that the average operating margin ((Revenue - Expenses)/Revenue) was only 1.5%. An operating margin of 3% to 5% is generally considered to be healthy in the non-profit sector (Harrison & Montalvo, 2002). This impacts the pay that is possible for Direct Support Professionals. The field is maintained on starvation wages, which affects the ability to recruit and retain qualified employees and ultimately, the quality of services.
The history of governmental underfunding has been noted in several places. Amy Hewitt (2013) suggests that the underfunding is so pervasive and so longstanding, that it is improper to suggest that there is a workforce crisis because crisis implies some sort of emergent problem. Underfunding, on the other hand, is simply the way of life in intellectual disability industry. Spreat (in press) illustrates the extent to which intellectual disability funding has lagged behind inflation and general government spending. In Pennsylvania, government spending increased by more than 90% over a recent 22 year period, while intellectual disability spending increased by only 23%. The distinction between the term, “crisis,” and the standard order of business in the intellectual disability field is perhaps moot. Providers are unable to attract and retain a sufficient number of qualified Direct Support Professionals.
Possible Remedies
The rallying cry within the intellectual disability field has been to pay Direct Support Professionals a living wage, and there has been some modest movement in this direction. In Pennsylvania, for example, intense lobbying efforts were followed by a modest increase in intellectual disability funding, which enable about 90% of providers to offer raises to Direct Support Professionals (Spreat, 2019a). But the issue of concern is not really what Direct Support Professionals are being paid, but rather the ability of provider agencies to hire sufficient numbers of qualified applicants. In Pennsylvania, the increase in wages appears to have been offset by improvements to the economy. No appreciable improvements in turnover or vacancy rate were noted (Spreat, 2019a).
The role of litigation to increase reimbursement rates seems to have been dismissed in the recent Armstrong v. Exceptional Child Center lawsuit (2015). Some suggest (Thaler, 2017) that things will improve once the boomer generation passes on. This logic would seem to discourage legislators from taking any significant actions. Perhaps provider agencies would be wise to develop Political Action Committees and use those funds in an effort to persuade legislators. Others suggest that robots and other technological advances will replace Direct Support Professionals in the future. Until that time, provider agencies must survive.
Modest wage increases may be possible through legal lobbying and educational efforts, but rate increases of 2-3% per year will not enable the field to overcome the roughly 67% lag behind governmental spending referenced above.
The conditions described above are bleak, and one must reasonably wonder whether the intellectual disability field will be able to sustain itself. More funds from the government seem unlikely. An influx of qualified individuals who want to become Direct Support Professionals also seems unlikely under current conditions. How is the field to face the challenge of supporting and serving individuals who have intellectual disability?
An Alternative Remedy
One approach to address this problem involves a re-conceptualization of the Direct Support Professional position. There are those for whom the Direct Support Professional job is a wonderful life long career, and there are those for whom the Direct Support Professional position is a stepping stone to another career. It appears unlikely that the field is able to make the position itself a more attractive life long endeavor, but perhaps it can make the Director Support Professional job a more appealing stepping stone by providing staff with a variety of professional growth opportunities.
Education Options - Bogenschutz, Nord, and Hewitt (2015) report that specialized training can be effective in reducing employee turnover. In addition to improving the general knowledge and skill set of Direct Support Professionals per se, training and education can be provided to help Direct Support Professionals transition to other careers.
Woods Services first experienced this during the nursing shortage that occurred 10-12 years ago. Unable to hire a sufficient number of nurses, Woods was forced to hire and train technicians to deliver medications. Limited nursing resources were used for medical responsibilities and duties, while the technicians assumed responsibility for dispensing medications. The technicians were nested within the nursing department and worked directly with nurses. Subsequently, several medication technicians started to attend nursing classes. To date, 14 technicians have earned nursing degrees and licenses, eight of whom have elected to remain working at Woods, two of whom hold nursing management positions. Employee benefits in the form of tuition assistance paid for a portion of their educational expenses. The development of new nurses at Woods paved the way for other educational interventions.
More recently, Woods partnered with local colleges and universities to develop and offer highly discounted and on-site educational programs for its employees. A partnership was established with Harcum College to offer an Associate’s Degree in Human Services program for Woods employees. The initial cohort consisted of 12 employees, two of whom recently graduated. Twenty-five employees are currently enrolled in the Harcum program at Woods and six of them will graduate in May. Plans are underway to support these graduates to attain their Bachelor’s Degrees under a similar model. A second partnership was developed with the Philadelphia College of Osteopathic Medicine to offer a Master’s Degree program in Non-profit Leadership and Population Health Management for current and emerging organizational leaders. This program will graduate 23 employees this summer. A second cohort of 25 employees will begin the program in the fall 2020.
Woods recognizes that some of these graduates will leave the organization, but it is confident that they will go on to make meaningful contributions to the field. More than 90% of employees enrolled in these educational programs have remained employed at Woods throughout their schooling, and it is anticipated that most of them will remain employed through their contractually obligated two year post graduation period. The comparable retention rate for Woods employees not involved in these educational programs is 73% per year. The turnover rate for employees who are not engaged in these educational programs over a two year period is about 54% compared to a 10% turnover rate among employees who are involved in the educational programs.
A third educational opportunity emerged in response to Woods’ limited ability to grow its special education programs due to industry-wide challenges in recruiting appropriately credentialed special education teachers. Individuals who hold bachelor’s degrees can obtain temporary teaching credentials, but must work to obtain full credentials. Through this new initiative, Woods encourages its Direct Support Professionals with bachelor’s degrees to seek temporary teaching certification, and in return Woods supports them in completing the coursework needed to achieve permanent credentials. There are currently four employees enrolled in this program, and 14 additional employees are in the enrollment process and anticipate starting classes in the fall 2020.
These examples demonstrate that while education can be used to enhance performance in the job that an individual currently holds, it can also be used to enhance that individual’s professional preparation and advancement. Woods tends to keep employees who are engaged in its educational programs.
Motivational Opportunities – Woods is a large organization, and despite a general openness on the part of management, it can be easy for staff to feel relatively unimportant. To facilitate employee engagement with Woods, their jobs, and their careers, Woods conducts a competition each year. Through facilitated social innovation labs, groups of employees are encouraged to develop formal proposals to improve program quality. These proposals are presented to a panel of judges comprised of members of the board and executive leadership team of Woods, which selects the most promising proposals for funding. Funding comes largely from the organization’s foundation.
Over the past three years, Woods has funded ten proposals submitted by staff. Among the funded projects are initiatives that increase the employability of clients through social enterprises, teach individuals gardening skills, market Woods products to the general public, and reduce client travel time and costs. Perhaps more important than the actual projects, staff are encouraged to voice recommendations about how to enhance programs and services and in a sense, become involved in the actual leadership of the organization.
Conclusion
Efforts to increase Direct Support Professional wages must continue, but these efforts need to be supplemented by non-economic actions that assist employees in developing and enhancing their readiness for higher levels of employment. This sort of action appears to retain employees longer, and with appropriate marketing, will attract new employees to the organization. Both recruitment and retention can be enhanced. The downside of this approach is that some employees will eventually move to jobs outside of the organization. These are tolerable losses as these employees will have assisted in the development of their co-workers that elect to remain as well as go on to make contributions to the field. This approach makes employment as a Direct Support Professional at Woods an attractive stepping stone.
While this approach may encourage some employees to move on to other jobs, others will remain working for the organization in roles with higher levels of responsibility and their success will ultimately make the Direct Support Professional job more attractive to potential employees. Admittedly, the position itself will continue to be undercompensated, BUT Direct Support Professionals will be afforded opportunities to learn and grown, and achieve their highest potential.
References
Armstrong v. Exceptional Child Center. United States Supreme Court, 5/4/2015. Bogenshutz, M. Nord, D. & Hewitt, A. (2015). Competency based training and worker turnover in community supports for people with Intellectual and Developmental disabilities. Intellectual and Developmental Disabilities, 53(3), 192-195.
Harrison M, Montalvo C (2002). The financial health of California’s hospitals: A looming crisis. Health Affairs; 21(1): 118-126. Available at: https://www.healthaffairs.org/doi/10.1377/hlthaff.21.1.118. [Accessed from 11 Dec 2018]. https://doi.org/10.1377/hlthaff.21.1.118
Hewitt, A. (2013). Raising Expectations: The direct support professional workforce.
Presentation to The Arc National Conference, Seattle, Washington, 8/4/13.
Larson, S., Lakin, C., & Bruininks, R. (1998). Staff recruitment and retention: Study results and intervention strategies. Washington DC: AAMR
Pettinger, R. (2017). Price controls- advantages and disadvantages. (https://www.economicshelp.org/blog/621/econonics/) accessed 8/6/18.
President’s Committee on People with Intellectual Disabilities (sic). (2012). Managed Long Term Services and Supports: 2012 Report to the President. Washington DC: President’s Committee on People with Intellectual Disabilities (sic).
Spreat, S. (2019). Pennsylvania Direct Support Professional Wage Study. Langhorne, PA: Alliance of Community Service Providers (ACSP), Moving Agencies toward Excellence (MAX), Pennsylvania Advocacy and Resources for Autism and Intellectual Disability (PAR), Rehabilitation and Community Providers Association (RCPA), Arc of Pennsylvania (Arc/PA), The Provider Alliance (TPA), United Cerebral Palsy of Pennsylvania (UCPA).
Spreat, S. (2019). Revenue and Expenses over Five Years in Intellectual Disability Service Providers in Pennsylvania. Disability, CBR & Inclusive Development, 29(4), 98-108, DOI 10.5463/DCID.v29i4.797.
Spreat, S. (in press). The Crises in Intellectual Disability. London: Cambridge Scholars Publishing,
Thaler, N. (2017). Untitled presentation at PAR Solutions Conference. Harrisburg, PA.