Some Ways Tennessee Can Tackle DSP Workforce Crisis

By Janet Shouse

About the Author

Janet Shouse is a parent of a young adult with autism, and she is passionate about inclusion, employment of people with disabilities, medical issues related to developmental disabilities, supports and services, public policy, legislative initiatives, advocacy, and the intersection of faith and disability. She wears many hats at the Vanderbilt Kennedy Center, including one as a disability employment specialist for TennesseeWorks.

Our hope is that this weekly blog will offer information you want to know, so if you have a question you want answered about employment for people with disabilities or other mysteries of the world of work, please email me at janet.shouse@vumc.org.

In previous blog posts, I shared the findings of an audit of the Department of Intellectual and Developmental Disabilities and its Statewide Planning and Policy Council, with the second post focusing on Tennessee’s “crisis-level shortage” of direct support professionals. I also asked individuals and families to let me know about their experiences with this shortage.

One mother wrote, “I have witnessed several complete turnovers of staff in my adult daughter’s center-based program and have made several observations–many of those mirroring these findings.

  • Low pay.
  • No or little pre-service/in-service training provided to DSP. (The issue here is likely about the effectiveness of the training, because DSPs in Tennessee are required to complete about 40-50 hours of pre/early service training if they are supporting people with IDD.)
  • Workplace environment issues.
  • Lack of or little genuine appreciation by management for hard work.
  • Creativity in dealing with challenging behaviors not encouraged.

“I have since hired out-of-pocket a personal assistant who previously worked at this center. She is now flourishing and feeling valued with a stronger sense of purpose in working with my daughter. When I finally receive funding through ECF CHOICES (Employment and Community First CHOICES), I plan on supplementing her pay (using ‘consumer direction,’ which allows a pay rate of $15 an hour) to the rate of $15 per hour (she’s now at $10 per hour). She’s worth every penny and I will do whatever is necessary to keep her as long as I can.”

Another mother shared her son’s story.

“Through ECF, my now 26-year-old son is required to do the ‘Exploration’ phase. We completed that phase through ECF. Because of DSP shortage and turnover, we had to extend the deadline 3 times.”

She continued: “Courtney Henderson with WAVES is awesome – but she is one person. We then attempted to do Discovery — and kept having to reschedule until finally it became so frustrating that we just put it on hold. We are doing alternative activities for my son using PA (personal assistants) to ‘fill his cup.’”

Let me add a tidbit that makes perfect sense, but I had not considered, and it doesn’t involve the state or its efforts at all. A colleague pointed out how important it is that families understand how much their relationship with the DSPs who support their family member can influence a DSP to stay. So, families, if your loved one has a DSP who is wonderful, please let them know how much you appreciate him or her.

Now, let’s talk about ways our state might ease this crisis.

Since I wrote about this “emerging issue” a few weeks ago, I learned that the President’s Committee on People with Intellectual Disabilities released a report last year to the president entitled “America’s Direct Support Workforce Crisis: Effects on People with Intellectual Disabilities, Families, Communities and the U.S. Economy.”

The President’s Committee on People with Intellectual Disabilities promotes policies and initiatives that support independence and lifelong community inclusion.

You can read the committee’s report here.

Many of the concerns listed in this report track closely with the concerns listed by the recent audit of DIDD, so I won’t repeat them.

Among the recommendations of this federal committee to combat the workforce crisis are:

  • Include sufficient direct support professional wages and compensation packages in states’ rate-setting methodologies for long-term services and supports to people with intellectual and developmental disabilities.
  • Improve the professional identify of DSPs and recognize direct support as a valued career.
  • Help business and organizational leaders (community provider agencies) learn skills to improve their ability to find and keep DSPs.
  • Offer self-directed services that allow individuals and families to hire their own DSPs. (This option often allows a higher hourly pay rate for DSPs. The first story above illustrates this.)
  • Use worker cooperative and independent provider models. (Independent providers, or independent contractors, are self-employed and provide services directly to people with intellectual or developmental disabilities.)
  • Use competency-based training models that lead to credentialing or certification of staff and yield wage increases.
  • Use technology-enhanced supports.

The American Network of Community Options and Resources, which is an organization of community provider agencies, also offers solutions in a 2017 report entitled “Addressing the Disability Services Workforce Crisis of the 21st Century,” which can be accessed here. Those recommendations are very similar to those of the President’s Commission, but include suggestions for additional groups that provider agencies could recruit into the DSP occupation. (Currently, women ages 25-64 make up much of the DSP workforce, and recruitment efforts will need to expand to un- or underemployed men, recent high school graduates, college-age individuals, and people of retirement age.)

Tennessee is currently exploring most of these solutions.

The first is a proposed 1% increase for DSPs, personal assistants, and case management, which Gov. Bill Haslam has included his budget, and which the General Assembly will vote on in the coming months. And there have been changes in rate-setting with the Employment and Community First CHOICES program, with DIDD looking at similar changes as well.

As you may recall, DIDD held a technology summit last fall to explore use of technology, such as real-time remote monitoring and sensors, as a way to provide supports that might be safely used to reduce reliance on DSPs. DIDD Commissioner Debra Payne explained the technology in a previous blog. DIDD has currently selected four provider agencies to participate in its test project, which is expected to begin this spring.  Gov. Haslam has proposed $500,000 in recurring funding for enabling technology to allow Tennessee to grow these efforts.

TennCare officials believe that retention is key.  According to Patti Killingsworth, assistant commissioner and chief of Long-Term Services and Supports for TennCare, if Tennessee focuses on increasing providers’ ability to retain workers:

  • Recruitment challenges will be reduced.
  • Savings from reducing the costs of never-ending recruitment could be used to increase DSP wages/benefits.
  • People receiving services will get greater continuity, which also means better experience and outcomes for them.

TennCare is planning a three-pronged approach to this crisis. Ms. Killingsworth says, instead of solely increasing reimbursement rates and hoping but not knowing whether this will help, TennCare believes that efforts will be more successful if the state can target its investments to provide financial incentives and technical assistance to providers to support adoption of key practices that – when coupled with higher wages – have been shown to result in increased retention and better outcomes for people served.  These practices include:

  • Consistently using the most effective DSP recruitment and onboarding strategies, including targeted marketing, realistic job previews, and behavioral interviewing.
  • Providing high-quality competency-based pre/early service training.
  • Providing early access to mentoring by more experienced DSPs.

In addition, because many DSPs leave the field because they do not feel they were adequately prepared for the work, or they see no chance for professional advancement, TennCare is creating a competency-based education and training curriculum for which DSPs are expected to be able to earn college credit.  TennCare officials are in the process of working with the Tennessee Higher Education and Community College system with a goal to make this curriculum a reality by 2019. DSPs may be able to use the Tennessee Promise or Tennessee Reconnect funding to earn this college credit.

As a final note, TennCare officials also believe that the shortage of DSPs may not be solely about an inability to recruit and retain qualified staff.  They say if Tennessee can focus services and supports on helping people maximize their independence, ensuring people can rely on assistive technology to increase self-reliance, and helping people make use of the community supports, we can avoid having too many DSPs supporting too few of the people who need support.

While this contention that too many DSPs may be supporting too few people stirs a good deal of controversy in the disability community, one of the things that TennCare and DIDD officials heard during their stakeholder meetings in 2014 was that not everyone with ID or DD needs or wants support 24 hours a day. Our system has been primarily focused on 24/7 staffing over the years, but it is important for agencies to consider fading supports or providing fewer supports when it is appropriate. It will also be important for families to be willing to consider that other levels of support may be more appropriate for their loved one. This consideration involves the “dignity of risk” and can be a difficult decision for all involved. However, working with an individual to achieve greater independence can also make the work of a DSP more rewarding than functioning in a purely custodial care role.

So what do providers think of these solutions?

I contacted a provider agency for its perspective on this issue. Steve Cox, personnel director of Dawn of Hope Inc., a provider agency in Johnson City, TN, offered some thoughts.

His first thought touched on the story that the mother at the start of this blog shares. “We can surmise from this that in order to attract and retain a top-notch high level DSP (and what parent or provider wouldn’t want and expect that), the mother believes it is worth a minimum of $15.00 per hour.”

He also said, “Contrary to what TennCare’s philosophy may be and as a possible counter to that, there is an element of truth to stating ‘if you pay enough, you might not have to hope.’ Providers are not just in competition for talent with other providers, they are in competition with virtually every other employer in their local economy, most of whom pay their employees significantly more for jobs that entail far less training, responsibility and accountability than a DSP has. It starts with providing people a living wage, and until TennCare and DIDD acknowledge that, my fear is that very little else will have much impact, despite our best efforts.”

He noted that recommendations that include improving DSPs’ professional identity, developing different career models for DSPs that provide opportunities for promotion, and the use of competency-based training that leads to credentialing or certification of staff are ideas that have long been championed by providers.

“The issue however, always comes back to funding, or the lack thereof,” Mr. Cox said. “Motivating staff to become specialized or credentialed in a particular career path is difficult at best when there is little or no financial incentive for them to do so.”

As for the recommendation of greater use of technology, Mr. Cox said, “I attended DIDD’s Technology Summit last year and was extremely impressed with how some providers in other states are utilizing technology supports and how effective those supports can be in the right circumstances, but when applying those technologies to our organization I found that they would be appropriate for only one to four individuals out of the approximately 180 that we currently support.”

Mr. Cox also had concerns, in particular, about TennCare’s apparent belief that the shortage of DSPs may not be solely about an inability to recruit and retain staff.

“While the DSP shortage may not be ‘solely’ about the inability to recruit and retain qualified staff, it is almost certainly the primary cause and any insinuation to the contrary is ill-informed and irresponsible,” he said. “Speaking from our organization’s perspective, I can assure TennCare that we certainly do not have too many DSPs supporting too few of the people who need support. For the last few years, we have maintained a fairly constant rate of 35 DSP vacancies at any given time. That equates to having nearly a 17% vacancy rate for DSP positions. It is my belief that with vacancy rates like that, we, along with other providers, know better than anyone how to ‘fade supports’ when it is appropriate to do so.”

The DIDD audit closes this section on the DSP workforce crisis with this note. “The department, in conjunction with TennCare, is taking action to address this pressing (staffing) challenge. The agencies should continue to work together to explore innovative solutions, as workforce demands will only increase in years to come.”

As the parent of a young adult who currently receives Medicaid waiver services, I can only hope that these efforts will boost the number of people who choose to make this line of work their career. This workforce shortage and our state’s efforts to ease it are clearly going to be an ongoing discussion. I will continue to write about it and look forward to comments or questions by readers. Please feel free to email me at janet.shouse@vumc.org. Thanks!