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Does More Staff Make Individuals Safer?

Disruptive Innovations

In Pennsylvania, approximately 56,000 individuals with intellectual disabilities receive services through the state’s Office of Developmental Programs (ODP), which contracts with community providers to deliver services and supports under rigid quality and safety guidelines. Some of these guidelines are dated and were established at a time when data was not readily available. But even the smallest adjustments to these requirements are challenging to implement because changes take time and collaboration across many government departments and diverse stakeholders. 

For example, the staffing grid is a common tool used by state intellectual disability departments to determine staffing levels and is based on the notion that more staff minimizes accidents and makes individuals safer. Yet, a document created by ODP addressing fatalities in the system, the Fatal Four, does not identify the lack of staff as a primary reason for fatalities. Why then are Individual Service Plans (ISPs) based on the number of staff caring for individuals? Not only does this often prohibit individuals from living an “everyday life,” but it also costs the system additional money while creating an illusion of safety. Collectively the industry had decided that staffing ratios were a good measure of safety. At first glance, they seem to be. However, upon closer examination it becomes evident that the staffing grid provides a false sense of security for providers, individuals, caretakers, and funders, and often prevents individuals from experiencing an “everyday life,” does not provide additional safety, and even makes individuals less safe at times.

When ODP changed the waiver amendments in accordance with federal requirements in 2017, it changed the way residential providers are reimbursed, basing reimbursement rates on Supports Intensity Scale (SIS) scores rather than on staffing ratios. This change provided an opportunity for The Alliance of Community Services Providers to advocate for process improvements in regards to the staffing grid. Through collaboration and consensus building with providers and state and local government, changes that focus on actual safety and promoting an “Everyday Life” philosophy were achieved. 

Specifically, advocates recommended eliminating the staffing grid and for flexibility around the number of staff required at any given time. They reasoned that this would optimize funding as well as make it easier for individuals and providers to use technology to augment and supplement staffing and foster independence and a sense of accomplishment among service recipients. In an effort to change the staffing grid in Pennsylvania, a steering committee consisting of ODP, the Philadelphia Office of Intellectual Disabilities Services (IDS), service providers, and supports coordinators was convened. This committee quickly identified two key recommendations:

  1. Eliminate the residential staffing grid as the approved waiver amendments do not mention staffing grids or ratios, nor does Everyday Lives, a PA statewide document used as a guide by ODP as it develops policy and designs programs; and 
  2. In lieu of mandated staff ratios, determine the level of support a person needs based on activities specified in the ISP and describe the roles of staff during these activities. 

By way of an example of the second recommendation, "Mary" must have a person at arm's length distance while eating to assure that she does not aspirate. This makes it clear what is expected of the staff (a staff person must be arm's length distance from "Mary") and it clearly states the activity (eating) rather than time frames, e.g., Monday through Friday 8 a.m. to 4 p.m. The steering committee agreed that there could be exceptions to this and that, in some cases, a staffing ratio may be necessary to support specific billing codes. For example, "Mary" would require enhanced support, which may require justifying the credential of the staff rather than the number of staff. 

The steering committee advocated that a shift from staff focus to activity focus would improve safety and flexibility for the individual, the staff, and providers, ultimately leading to better and more integrated lives in the community. The committee acknowledged that these changes would have ripple effects on other parts of the system (e.g., changes to monitoring tools; licensing; quality assurance/quality improvement processes; and risk and incident management) and recommended that ODP pilot these changes among 30 individuals, four providers, and two supports coordination organizations (SCOs). A pilot was conducted and included the following elements:

  1. Identification of individuals 
    Each provider identified 10-12 individuals, and preference was given to individuals with pending ISP updates. The selection was based on diverse needs but with a focus on complex individuals.
  2. SCOs
    SCOs chose the seven to eight best-suited individuals per provider and kept it to a limited number of support coordinators to limit the training needed. However, the support coordinator normally assigned to the individual attended the ISP team meeting so existing relationships would not be disrupted. 
  3. Administrative Entity (AE) Support
    Philadelphia County identified a specific group of reviewers dedicated to this pilot to maintain continuity throughout the pilot.
  4. Service teams
    Trained service teams met to update the ISPs of selected participants, eliminating the residential staffing grid and specifying the level of staff support that was needed for each participant and activity/service -- as taught and now guided by the Support Coordinator of the service team.
  5. Debrief
    In a debriefing meeting with the steering committee everyone involved in this process provided feedback.  
  6. Recommendations 
    The Alliance of Community Service Providers presented the findings/recommendations of the pilot to ODP.

This pilot was expanded to two more rural counties to test it in less populated settings. These pilots were equally as successful, and after developing a training strategy that included webinars, face-to-face, and train-the-trainer sessions, the new staffing requirements were implemented in January 2020.

This initiative raised many philosophical questions. What are the challenges and why? How are service providers, SCOs, and the individual impacted? What does “Everyday Life” mean? How is safety measured? How much should safety impact the individual's access to an “Everyday Life”? When is safety an issue? Is constantly having staff around more prohibiting than supportive? What should be discussed in ISP meetings, and how should the meetings be conducted?

In the beginning, committee members were on very different sides of the spectrum regardless of who they represented. Towards the end, members gravitated towards the middle, and the committee was able to determine what it wanted to change and how. It is important to note that without the time consuming but very necessary philosophical discussions that occurred during the first six months, the Committee would never have been able to move forward. Furthermore, it would not have been able to successfully implement the pilots and ultimately this small but significant system change. 

Author Bio

Karin Annerhed-Harris joined the Alliance of Community Service Providers in 2013 as the Associate Director, responsible for collaborating with policymakers on a city, state, and national level. Karin educates policymakers on the importance of providing strong and sufficient human service programs for individuals with intellectual disabilities, mental health and/or substance use disorders, and children services. A strong supporter of innovation and with a focus on continuously improving social systems through research and collaboration with diverse industries and government, she serves on the advisory board of the Social Innovations Journal. 

The Alliance of Community Service Providers is a professional membership organization representing more than 65 nonprofit and for-profit organizations in Southeastern Pennsylvania that provide supports and services for adults and children with intellectual disabilities, those with mental health issues, and people recovering from addictions. Together, the members of the Alliance serve more than 200,000 people annually, employ tens of thousands of people, and generate hundreds of millions of dollars in economic activity.