Prepared for the Alliance for Consumer Options by representatives of:

• Arc Minnesota
• Association of Residential Resources in Minnesota
• Institute on Community Integration, University of Minnesota
• Minnesota Habilitation Coalition
• Minnesota Association of Mental Health Residential Facilities
• Minnesota Association of Professionals in Supported Employment
• Minnesota Association of Community Rehabilitation Organizations
• Minnesota Semi-Independent Living Services
• Minnesota Consortium for Citizens with Disabilities
• Minnesota Home Care Association
• People First, Minnesota

If you have questions or comments about this report please forward them to Lynn Megan, Chair, Alliance for Consumer Options, c/o REM-MN Inc., 3201 W. 69th St., Edina, MN 55435. Phone 612-922-6776.

Executive Summary

Minnesota faces enormous challenges recruiting, training and retaining direct support workers in human services. An estimated 32,500 direct support workers (DSW's) and 3,500 supervisors support people with mental retardation in Rule 18, 34, and 42 residential and Rule 38 vocational settings, and people with mental illness in Rule 36 community residential settings. Demographic pressures from shrinking young adult populations, economic pressures from extremely low unemployment and shrinking real dollar wages for direct support workers contribute to this challenge.

To respond, Minnesota must create a comprehensive and effective workforce development program to plan and maintain community services for all Minnesotans with disabilities. This comprehensive program must be available to all public and private service providers in Minnesota. It must develop, identify and support strategies to address labor shortages, high turnover rates, low wages and low productivity in the human services industry.

This effort will require cooperation from the state Departments of Human Services, Labor and Industry, Economic Security, Jobs and Training, Children, Families and Learning, public and private provider agencies, consumer and parent advocacy organizations such as Advocating Change Together and the Arc, and post-secondary educational institutions (including the Minnesota State Colleges and Universities). This document identifies specific short and long-term strategies to address workforce challenges and makes recommendations regarding legislative action that would be necessary to carry out these solutions.

Recruitment Strategies:

• Expand the pool of DSW's through the Minnesota School-to-Work, Tech-Prep, Welfare-to-Work, Return-to-Work and Displaced Worker programs.
• Target recruitment, training and support programs (age and culture)
• Improve DSW wages and benefits.
• Develop a better understanding of the nature and needs of DSW workforce.

Retention Strategies:

• Develop realistic job previews.
• Provide assistance and training to measure and reduce staff turnover.
• Develop a program to enhance the status of DSW's.

Education and Training Strategies:
• Identify DSW training needs.
• Develop, identify and distribute competency based training materials.
• Provide technical assistance, training and support on the delivery of training.
• Expand training and career development opportunities for DSWs.
• Develop a competency-based training program for supervisors of DSWs.

Studies of Efficiency and Productivity:

• Examine the cost implications of recruitment and retention outcomes.
• Examine cost efficiencies possible within the current service delivery system.
• Examine DSW roles.
• Promote consumer directed services.
• Work with DD managed care pilots to develop efficient personnel practices.

Background Information

Minnesota will face enormous challenges in the next decade in recruiting, training and retaining direct support staff. Demographic pressures from shrinking young adult populations, economic pressures from extremely low unemployment and shrinking real dollar wages for direct support workers will contribute to this challenge. Personnel Initiative '97 recognizes that current efforts to recruit, train and keep a competent workforce to support Minnesotans with disabilities in their communities will not be adequate. Without an effective comprehensive workforce development program, commitments to provide people with disabilities safe and integrated housing cannot be kept.

Continuing efforts to downsize and close large congregate residential settings, increase integrated educational experiences, increase community work and recreational experiences and provide real choices in how supports are delivered for people with various disabilities require an effective systematic approach to workforce development. This report documents the need for a comprehensive new approach, and identifies strategies to address growing recruitment, retention and training challenges surrounding direct support workers who provide supports persons with disabilities in Minnesota.

The human service industry has changed dramatically in recent years. A generation ago, institutional care was the primary model for supporting people with disabilities. Today, most people with disabilities who receive supports live in their own homes, with family members or in small community settings. In 1977, 3,000 Minnesotans with developmental disabilities lived in state institutions, but by 1996 that number was less than 300. In contrast, the number of Minnesotans with developmental disabilities receiving residential supports in settings with fewer than 15 people increased from 1,200 to more than 11,000 during those same years (Prouty & Lakin, 1996). The number of Minnesotans with developmental disabilities in paid community employment with ongoing job supports increased from 1,118 in 1985 to 3,200 in 1991 (Nichols, 1993).

Similar changes have occurred in human service sectors serving people with other types of disabilities as well. For example, the MN Department of Human Services estimated in 1995 that 1,287 people with mental health needs were served in community Rule 36 facilities in 1995. A total of 20,100 Minnesotans receive SSI or SSDI based on a mental health diagnosis.

As services become more decentralized, training needs change, turnover rates increase, and the demand for workers increases. These increasing problems, especially intense among direct support workers, require specific intervention to resolve.

The Direct Support Workforce  

Direct Support Workers are people who provide support, training, supervision and personal assistance to people with disabilities. They support persons with disabilities in basic self-care and independent living activities and help them to lead self-directed lives of active participation in and contribution to community life. Direct support workers have a variety of titles and positions such as job coach, residential counselor, paraprofessional, direct care staff, personal care attendant, homemaker, and paraeducator. They work in public and private group homes, institutions, home health care agencies, schools, vocational agencies, camps, psychiatric facilities and other settings. They support people of all ages who have various needs and disabilities (e.g., people with mental retardation, people who are elderly, people with mental illness). It is not uncommon for one direct support worker to work in two or more settings, supporting people with various disabilities.

The exact number of direct support workers in Minnesota is unknown, but an October 1996 study estimates that there are at least 32,500 direct support workers and 3,500 first line supervisors in Rule 18, 34 or 42 residential and Rule 38 vocational settings supporting people with mental retardation and in Rule 36 residential programs supporting people with mental illness (Larson, 1996a). An additional unknown number of workers are employed in state institutions, schools, recreational settings, nursing homes, and in agencies providing in-home personal care attendant or certified nursing assistant supports.

Workforce development for human service workers has become increasingly more difficult due to several demographic and labor market trends. Bureau of Labor Statistics project a 136% increase in the number of human service workers and a 120% increase in the number of personal and home care aides by the year 2005 (Kilborn, 1994). For every ten newly created jobs in the United States, eight are projected to be service positions. However, the number of Minnesotans ages 18 to 44 (accounting for 80% to 90% of all direct support workers) is projected to drop by 3.75% between 1995 and 2010 (U.S. Bureau of the Census, 1994). Thus we can no longer depend on this pool of workers as the only or the primary pool from which to draw new workers.

Nature and Magnitude of the Direct Support Workforce Crisis in Minnesota  

Recognizing the importance of recruitment, retention and training challenges, several federal and local research and demonstration projects have been funded in Minnesota to describe the direct support workforce and to respond to the challenges of maintaining a sufficient size and quality workforce to meet Minnesota's commitments.  

Retention Challenges  

One federally funded study followed 175 newly hired direct support staff members in 139 small Minnesota group homes to describe the basic characteristics of residential direct support work (Larson, 1996b). Turnover rates among direct support workers in this study averaged 47% per year in 1994 and 50% per year in 1995. Even more challenging, of direct support workers who left during the previous 12 months, 41% had left before finishing six months on the job, and another 25% left before finishing 12 months on the job. In this study, only 58.3% of all direct support workers were eligible for benefits (e.g., medical, dental), and only 71.8% were eligible for paid leave (e.g., vacation, sick, holiday). Average beginning wages for residential direct support workers were $6.97 with average highest wages at $9.15 per hour. A separate 1995 survey of 61 residential provider agencies found that direct support workers working 1st or 2nd shift hours earned an average statewide of $7.28 per hour (Hafdahl, 1995).

Recruitment Challenges  

An October 1996 study described recruitment challenges faced by 144 randomly selected residential, vocational, in-home support, and mental health agencies in Minnesota (of 488 eligible agencies) (Larson, 1996a). Both public and private agencies providing various types of supports to people with disabilities have reported difficulties in recruiting and retaining new workers. Approximately 9% of direct support positions and 5% of the first line supervisor positions were vacant at the time of this survey. This represents an estimated 2,860 direct support vacancies (1,420 FTE positions), and 118 first line supervisor vacancies. These are vacancies for which money has been allocated to meet identified needs of people with disabilities which providers are struggling to fill. In addition, with turnover rates of almost 50% annually, 15,250 direct support positions have to be filled each year to replace workers who have left. Additional new direct support workers have to be hired to provide services to the estimated 2,156 new people with disabilities who begin receiving services each year statewide (an estimated 1,340 direct support workers). Substantial resources are devoted to advertising and overtime expenses as a result.

Agencies responding to the recruitment survey reported spending $47,880 for advertising just during August 1996. This translates into estimated annual recruitment costs across the 488 agencies statewide of approximately 1.95 million dollars. In addition, these agencies paid for 28,497 hours of overtime in August 1996. This translates into an estimated 1.15 million hours annually. If the average worker in Minnesota earned $7.28 per hour, this represents 4.22 million dollars annually in overtime expenditures (beyond the straight time expenses). If recruitment and retention challenges could be addressed, this money could be reinvested in current workers to provide salary or benefit increases or could be used to provide additional services or supports to people with disabilities.

Direct support worker positions were vacant for an average of 3.1 weeks before being filled, and first line supervisor positions were vacant for an average of 2.4 weeks. When direct support worker positions were advertised, the average agency received 10.0 applications. Some providers had much more difficulty. One southern Minnesota residential provider had nine applicants for 35 open positions. A northern Minnesota provider reported receiving two applications for 10 vacant positions. Similarly a metro area provider received eight applications for 12 open positions. These examples clearly present the need for a targeted systemic workforce development plan to address challenges facing the human services industry.

In the study of new residential workers, newly hired direct support workers reported that the most important factors influencing their decision to stay or leave were compensation (e.g., lack of benefits, low wages, no raises), other staff members (e.g., lack of team work, gossip, poor job performance by coworkers), and supervisor skills (e.g., poor leadership, unfair treatment). Direct support workers who quit reported that they quit because they wanted a different type of job or because of problems with the people they were supporting, wages, or poor supervision. These findings suggest that along with compensation, supervisory training and performance clearly impact the personnel crisis faced by human service agencies.

Executive Directors and Administrators in the recruitment study said that wage and hour considerations (69%), finding qualified staff members (69%), and staff turnover (57%) were major problems for their agencies. The top three recruitment barriers or disincentives were lack of qualified applicants (69% of all agencies reported this to be a moderate or a severe barrier), lack of applicants (67%), and compensation or pay (67%). Some variations in the ranking of these barriers were evident in agencies of different types. Information about turnover rates and causes of turnover is not available in Minnesota for workers in vocational agencies serving people with developmental disabilities or in Rule 36 residential agencies supporting people with mental illness. Available information, however clearly identifies recruitment as a significant issue for provider agencies. Shortages of applicants and inadequate wages are considered major contributors to the problem.

Training Challenges  

The 1992 Minnesota Task Force on Direct Service Personnel Training found that access to current training materials and on-going support for training personnel were among the most pressing needs in improving the quality of direct services to Minnesotans with developmental disabilities (Nichols, 1993). In addition, the lack of career mobility and career ladders for direct support workers makes it difficult for workers to advance once they are hired. Direct support workers report feelings of stagnation and burn out as a result.

Direct support workers are being asked to do more and to serve more people with significant medical and behavioral challenges in dispersed community settings. The result is a change in the training needs and roles of direct support workers. In a comprehensive national job analysis and needs assessment, a recent study identified 144 skill standards unique to providing community based services to people with disabilities. These skills are summarized in a report called The community supports skill standards: Tools for managing change and achieving outcomes (Taylor, Bradley & Warren, 1996). Twelve broad competency areas were identified including: participant empowerment; communication; assessment; community and service networking; facilitation of services; community living and supports; education, training and self-development; advocacy; vocational, educational and career support, crisis intervention, organizational participation and documentation. This careful study provides guidance about the training needs of direct support workers and their supervisors.

Despite our growing knowledge of training needs, several training challenges make meeting those needs difficult. According to supervisors, the most difficult training issues regarding direct support workers are arranging training times so staff can attend (70%), providing training that results in changes in job performance (53%), finding conferences, courses or workshops that are reasonably priced (42%), and finding incentives to motivate staff to attend training (41%) (Larson, 1996b).

Factors Impacting Workforce Issues  

Recent research has shown that recruitment, training and retention challenges are intertwined. Recruitment is a challenge because of growth in services, but also because of turnover among current employees. Training is a challenge because most new workers stay less than a year, creating a never ending demand to train newcomers. Substantial training resources are now being spent on new hires who do not stay long, or retraining current employees on the same information they had been trained on before providing little opportunity for long-term workers to receive new continuing education.

The factors influencing workforce development issues are also intertwined. Based on previous research, factors associated with staff turnover include:

• staff characteristics (older workers women, and workers with less education are less likely to leave).
• pay and benefits (higher paid workers with health insurance and paid leave time are less likely to leave).
• work attitudes (workers whose pre-hire expectations are met, who are satisfied with their jobs, who are committed to the organization are less likely to leave).
• employment context (turnover is higher when unemployment is lower).
• agency characteristics (turnover is higher in sites serving fewer people with disabilities and in sites supporting people with more severe disabilities).

Interventions are likely to influence not only retention, but training and recruitment as well.

Together these findings suggest that successful efforts to address work force issues will need to address not only wages and benefits, but also issues such as recruitment practices, staff socialization and training efforts, supervisor training and development, and employee work attitudes to be successful. Possible interventions include: providing realistic industry previews to recruit high school and vocational college students, providing access to livable wages for all direct support workers, improving access to benefits and paid leave for part time workers, beginning specific recruitment incentive programs, improving access to well-designed socialization and training programs, and working with the welfare to work program to match workers from around the state who want and need to work with vacancies in human service agencies. The challenge is to balance the need for increased funding to support wages and benefits that at a minimum keep pace with increases in the cost of living with the need to find ways to share other potential solutions with agencies statewide, to test the relative effectiveness of various strategies, and to implement broadly the most effective interventions to address recruitment, retention and training challenges.

Support for Addressing Direct Support Workforce Challenges  

The need for a solution to these workforce challenges was acknowledged in a recent position statement by Arc Minnesota. That statement said in part:

  "Arc Minnesota believes that staff recruitment, development and retention are essential to achieve tangible outcomes for people with developmental disabilities and their families. Comprehensive, ongoing development is mandatory. Arc Minnesota calls on the State's community and technical colleges, other institutions of higher education, businesses and government agencies to work with providers, parents and advocacy organizations to recruit, train and retain competent staff to serve people with developmental disabilities and their families."  

Other groups have also commented on this need in recent years. For example, a report on 12 "town meetings" held throughout Minnesota in 1992 by the Minnesota Governor's Planning Council on Developmental Disabilities and the Department of Human Services stated that "in every town meeting, there were repeated comments about the quality of staff in community programs, the impact that lower pay levels in the community have on staff turnover, and the need for training" (Governor's Planning Council, 1992, p.22).

To respond, Minnesota must create a comprehensive and effective workforce development program to plan and maintain community services for all Minnesotans with disabilities. This comprehensive program must be available to all public and private service providers within Minnesota. It must develop, identify and support specific strategies to address labor shortages, high turnover rates, low wages and low productivity in the human services industry. Accomplishing this will require cooperation from the state Departments of Human Services, Labor and Industry, Economic Security, Jobs and Training, Children, Families and Learning, public and private provider agencies, consumer and parent advocacy organizations such as ACT and Arc, and the post-secondary education sector (including the Minnesota State Colleges and Universities).

The remainder of this document identifies specific short and long-term strategies to address the challenges noted here, and makes recommendations regarding legislative action that would be necessary to carry out these solutions.

Current Efforts to Address Workforce Development Issues  

In 1991, the Minnesota Legislature mandated the creation of a broadly representative Task Force on Direct Service Personnel Training to develop recommendations, plans and actions to respond to a decade of documented need to improve the training of direct support workers in Minnesota. The task force report, released in 1993 identified broad recommendations to address six areas of need:

1. To secure interagency cooperation and collaboration.
2. To secure adequate funding to sustain a delivery system.
3. To develop curriculum and training materials that emphasize skills and are competency-based.
4. To effectively disseminate training and educational materials and resources.
5. To develop a process to evaluate education and training materials that is value- and outcome-based.
6. To include incentives that will address low wages, high turnover, and staff retention problems.

The Minnesota Direct Service Training Initiative was implemented as a means of addressing the goals of the Task Force Report. It is a collaborative effort between the Department of Human Services, the Governor's Planning Council on Developmental Disabilities, Minnesota State Colleges and Universities, the University of Minnesota, and other public and private agencies. The Initiative was jointly funded for a three-year period (1994-1996) by the U.S. Administration on Developmental Disabilities and the Minnesota Department of Human Services. The funding was subsequently extended for one additional year (1996-1997) but is scheduled to end in June 1997. Throughout this time period additional funding for MSDSTI efforts were funded by the Governor's Planning Council, the Minnesota Legislature, Minnesota State Colleges and Universities and a private foundation.

The Research and Training Center on Community Living/Institute on Community Integration has assumed leadership in achieving Goals 1,3,4 and 5 from the Task Force report. In the process, it developed the capacity to design, deliver and support high quality training, technical assistance, curriculum development and evaluation for direct support workers, personnel trainers, supervisors and lead workers. This training and support is provided directly, through training of agency personnel and in working with agencies to establish "third party" programs through technical colleges. While area six was addressed through related research projects, recruitment and retention of direct service workers has now emerged as a primary workforce issue to be addressed.

Components of a Comprehensive Workforce Development Program  

The Alliance for Consumer Options and its member organizations recommend that Minnesota establish a comprehensive Workforce Development Program that promotes collaboration between the industry and key stakeholders to identify critical workforce problems and to work with the Minnesota Departments of Human Services, Economic Security, Labor and Industry, Children, Families and Learning and the Minnesota State Colleges and Universities to develop ongoing strategies that respond to these workforce problems. This effort is the logical next step in continuing to address the workforce issues identified in 1993, and reaffirmed in the information presented earlier in this document.

The workforce development program should develop and implement specific strategies to address recruitment, retention and training issues and should study and identify inefficiencies within the developmental disabilities industry where cost savings could be reinvested in the workforce. It includes strategies to address the problems facing the industry with respect to direct support workers and their supervisors. Although this document organizes these strategies into recruitment, retention and training strategies, in reality these three areas are interrelated so that an intervention in one area is likely to influence outcomes in the other two areas as well.

I. RECRUITMENT STRATEGIES

1. Expanding the pool of potential direct support workers:

    Expanding the direct support workforce depends on increasing the numbers of people who know about, understand the requirements of and consider the possibilities of direct support careers. Three specific strategies to increase the number of direct support workers are proposed here.

• Minnesota school-to-work and tech-prep programs.

The direct support workforce must become a target industry within the Minnesota school-to-work and tech prep programs so that every high school student has exposure to human services as a viable career option through the presentation of realistic job previews, volunteer experiences, and paid work opportunities. Direct support should also be presented as a pathway to various other careers including: social work, psychology, physical therapy, nursing, medicine, and teaching.

As Minnesota embarks on further school-to-work efforts, the linkages of industry, post-secondary schools and secondary schools around this issue is essential. Currently there are no systemic efforts within tech prep or school-to-work to provide educational, work-based learning and work opportunities in human services for Minnesota's youth. In order to meet the challenge of 3,000 current openings and 17,000 additional openings each year, human services must become an integrated component of school-to-work efforts.

• Minnesota welfare-to-work, return-to work and displaced worker programs.

The human service direct support workforce must also become a target industry within existing and any newly developed welfare reform and welfare-to-work initiatives within Minnesota to provide jobs to people currently receiving welfare benefits and those who are at risk of losing benefits and for displaced workers who have been laid off or displaced from previous positions.

The Department of Human Services should join forces with state and county welfare-to-work programs to develop specific education and recruitment programs to recruit people into direct support work. Welfare-to-work dollars needed to be specifically targeted for the development of this workforce development program.

Additionally, this program should work with existing community service centers and career placement and training services to implement training and education programs for displaced workers and people who are chronically unemployed as an effort to recruit people in need of jobs into human services work. This effort needs to provide potential new workers with job counseling, assessment, realistic job previews, orientation and training. One possible model for replication is the Metro Area Consortium. That program has successfully collaborated with jobs and training, post-secondary educators, the University of Minnesota's Institute on Community Integration and the human services industry to recruit, train, support and employ new direct support workers.

• Targeted recruitment, training and support efforts.

The workforce in Minnesota suffers from chronic under representation of ethnic and cultural minority members. A comprehensive workforce development program should work directly with community organizations within Minnesota's communities of color to develop specific recruitment and education programs targeted to attract people from diverse cultural backgrounds (e.g., Asian Americans, Native Americans, African Americans) into human services work. This effort should be offered with agencies serving persons from diverse communities.

The workforce also suffers from chronic under representation of men and older citizens. For too long, the industry has relied on young women to provide direct support. As the societal demographics and the U.S. labor market change, it becomes critical to develop specific targeted recruitment programs toward non-traditional workers. This effort should be offered with agencies serving persons from these communities.

2. Improve the wages and benefits of direct support workers.

It is increasingly difficult to draw new recruits into the field of direct service work. Direct service wages do not keep pace with inflation. Many direct support workers earn wages that are below the poverty level for a family of four and are eligible for food stamps. It is often necessary for direct support workers work more than one job to support their families. It will be very difficult, if not impossible, for provider agencies to draw new recruits if serious efforts are not made to address chronic low wages within the industry. Assistance is needed from the Minnesota Legislature to provide a systematic means for ensuring cost of living adjustments for direct support workers.

However, it will require substantial resources to increase direct support worker wages. Based on what we know about numbers of direct support workers, it would cost approximately $33.8 million just to raise the average wage 50 cents per hour. It would cost substantially more to increase community residential worker wages to the level that workers in state operated community settings earn.

The Minnesota Legislature should work with the related state departments and industry leaders to create mechanisms to adequately compensate direct support workers. Specific strategies must be identified to provide reasonable compensation and to ensure that wage levels are supported with ongoing cost of living adjustments. Alternate compensation strategies must also be explored. Those strategies may include building a compensation structure based on competency and skill sets, allowing tuition credits for hours worked, providing discounts in stores or providing flexible benefit packages, tuition waivers, tax credits or loan forgiving.

3. Develop a better understanding of the nature and needs of the DSW workforce

The workforce development program must work with the Department of Human Services and the Department of Economic Security to reach agreement about the composition of the direct support workforce. Currently, the exact number of direct support workers Minnesota is unknown. Statistics collected by the Department of Economic Security (DES) do not categorize direct support workers in the same way as the industry does. Systems to collect accurate information on the current direct support workforce must be established to predict and describe labor shortages and to develop effective strategies to recruit workers. This is particularly important since the Department of Human Service's stated goals of deinstitutionalization, downsizing and expansion of inclusive programs for people with developmental disabilities will lead to continued growth in the demand for direct support workers.

Not only do we need to implement approaches for identifying the direct support workforce across disability services, (including PCA's, in-home workers, ICF/SLS workers, foster care workers, SILS workers, supported employment job coaches, day training and habilitation workers, RTC/SOCs staff, recreation staff, Rule 36/38 workers) we must also describe its current and changing nature. Important questions include:

1. How many direct support workers are employed across all disabilities services in Minnesota?
2. What are direct support worker wages?
3. How often do direct support workers leave their positions?
4. How long do direct support workers stay in positions?
5. How many vacancies exist in current services for people with disabilities?
6. What are the characteristics of direct support workers?
7. What are essential and available job benefits for direct support workers?

II. RETENTION STRATEGIES

For too long Minnesota has viewed personnel issues as the problem of individual agencies. The inefficiencies of this approach are no longer affordable, but more importantly, have led to great variability across agencies in knowledge and effectiveness in personnel areas. Personnel issues and knowledge about them must find a more significant place in Minnesota's service system. Although this is an area of many potential activities, four initial activities are needed because of their direct relationship with workforce challenges.

1. Develop realistic job preview strategies.

Research clearly shows that having a realistic idea about the content of a job is related to whether new hires will leave the job prematurely. Realistic job preview (RJP) techniques can provide such information to potential recruits. General industry previews can help high school and technical college students, displaced workers, and welfare recipients with a general overview of direct support work. However, each agency must also develop its own realistic job preview to inform potential recruits about the agency and unique characteristics of specific positions within the agency. Although RJP's are a validated approach to addressing turnover, provider agencies in Minnesota are generally unaware of the technique. Several have requested technical assistance and training on how to develop a realistic recruitment program to reduce the proportion of new hires who leave during their first six months on the job. A project is needed to develop a protocol for agencies to use when developing their own RJPs.

2. Provide technical assistance and training to measure and reduce staff turnover.

Each year, for every ten direct care staff positions at least five workers leave their jobs. Recent research and technical assistance efforts by staff at the Institute on Community Integration have identified strategies to measure and reduce turnover. However, knowledge of how to measure and reduce turnover is uneven across provider agencies, and, within agencies, across programs and supervisors. Minnesota needs to develop programs to help providers measure turnover and to develop specific strategies within their agencies to reduce turnover. Information developed under this activity could become part of a formal information exchange (e.g., on a computer bulletin board) between agencies and researchers about successful strategies.

3. Develop a program to enhance the status of direct support work.

Direct support work is under valued. Minnesota needs to develop a comprehensive, collaborative plan for enhancing the status and public image of direct support workers in Minnesota. The plan may include strategies such as public service announcements, awards, articles, high quality newsletters, recognition, a "direct support workers month," professional development workshops and so forth. It also might include an annual statewide conference for direct support workers.        

III. EDUCATION AND TRAINING STRATEGIES  

Improved preservice and inservice training has become critical as direct support workers increasingly work in small isolated community settings with minimal supervision and peer support. Workers have increased autonomy and responsibility for independent decision making. These changes require an evolving system to train and support direct support workers so that they continue to provide high quality supports to people with disabilities. This increase in need for training comes at a time when years of below-inflation rate increases have caused a substantial pinching of training budgets.

For the past three years, many of these needs have been addressed through a project to carry out the recommendations made to the Legislature in Minnesota Technical College Task Force Report on Training Direct Service Providers. These efforts involve a collaborative effort between the Minnesota Governors Council on Developmental Disabilities the Minnesota State Colleges and Universities, and the University of Minnesota, Institute on Community Integration to develop and carry out the Minnesota Statewide Direct Service Training Initiative (MSDSTI). Funding to support activities of the MSDSTI came from a variety of sources:

• Federal Department of Health and Human Services, Administration on Developmental Disabilities: $351,000.
• Minnesota Department of Human Services: $150,000.
• Minnesota Governor's Council on Developmental Disabilities: $190,500.
• Minnesota State Colleges and Universities: $50,000.

Effective June 30, 1997 Minnesota will no longer receive federal dollars to support the MSDSTI. Continuation and extension of the activities of the MSDSTI requires that the Minnesota Department of Human Service together with other governmental departments make ongoing funding available to support these activities. Funding is needed to support several education and training efforts.

1. Identify direct support training needs.

Although a national skill standards set has been identified, Minnesota needs a systematic means for identifying ongoing direct support training needs, including subject matter, methods of delivery (e.g., classroom, video, multi-media CD ROM, distance learning), times of delivery and current existing and needed access. This process requires constant attention as direct support work continues to change and mature.

2. Develop, identify and distribute competency based training materials

    The development of effective, high quality, up-to-date training material is costly and challenging for service providers. Minnesota has been involved in several projects over the years to develop training materials. Ongoing efforts are needed to systematically update materials and to distribute these materials to people in training roles throughout the state. Duplication of effort by provider agencies to develop and update material is inefficient. This activity may include developing, revising and distributing information about available materials as well as providing updated information about statewide training opportunities (e.g., on a statewide training calendar).

3. Provide technical assistance, training and support on the delivery of training.

Some agencies do a great job of coordinating training opportunities for their workers but others struggle. This activity would provide technical assistance to provider agencies on developing competency based training programs within their agencies based on the individual needs of the persons receiving services. It would also provide assistance for agencies to develop and deliver cross-agency and regional training programs to maximize the efficiency of training delivery.

Activities might include the identification, development and distribution of information on the use of technology to train direct support workers cost efficiently. Activities might also include an annual statewide conference for direct support workers like the "Putting People First" conference held in October 1996. A conference of this sort would provide opportunities for direct support workers to understand their role in the overall service delivery system, and would provide much needed opportunities to network with other direct support workers.

Finally, this effort would provide technical assistance and training to people with developmental disabilities and families who want to become effective trainers and supervisors of direct support workers. This activity would create education, training and technical assistance programs for consumers and families on how to recruit, retain and train direct support workers under individually controlled budget programs proposed by the Pilot Projects.

4. Expand training and career development opportunities for direct support workers

This activity would provide incentives for agencies to provide educational opportunities that lead to career tracks for direct support workers, lead workers and supervisors (e.g., reduced tuition costs, increase pay for workers who have completed the Community Supports Program, transferability of training across provider agencies in all services, approval of the courses within the Community Supports Program as meeting continuing education requirements within rules and regulations).

It would involve developing a systematic means to update and revise the Community Supports Program for People with Disabilities, and expand the availability of the Community Supports Program to additional technical/ community colleges, community centers, job training programs and provider agencies throughout Minnesota. It would also work to develop a seamless transfer of credits from the Community Supports Program into four year degree programs throughout Minnesota. It would include efforts to ensure that training hour requirements were supported with training dollars to complete those requirements. Finally, it would complete a comprehensive evaluation of the Community Supports Program.

5. Develop a comprehensive, competency-based training program for supervisors of direct support workers and lead workers.

Direct support worker turnover is related both to supervisor turnover and to supervisor competence. The first step in developing a training program for lead workers and supervisors is to collaborate with industry and educators to complete a job analysis and training needs assessment for supervisors of direct support workers, including subject matter, methods of delivery (e.g., classroom, video, multi-media CD-ROM, distance learning), times of delivery and current existing and needed access.

The second step is to develop and distribute training materials for trainers of direct support supervisors. This includes identifying and evaluating existing training materials for supervisors and lead workers and disseminating comprehensive reviews of these materials to the provider community on an ongoing basis through the continued publication and electronic dissemination of A Guide to High Quality Direct support Training Materials. This also includes collaborating with the provider community and other interested parties to develop an ongoing means to update existing training materials developed by the Minnesota Department of Human Services, to develop new training materials as needed and to distribute training materials to interested parties.

The final step is to work with the provider industry, advocacy organizations, post-secondary educators and other interested parties to develop and implement a comprehensive, cost-efficient training program for supervisors and lead workers that builds on the Community Supports Program. This involves providing technical assistance to provider agencies on developing competency based training programs within their agencies designed for supervisors and lead workers. It also includes providing technical assistance and training to people with developmental disabilities and families who want to become effective trainers for supervisors of direct support workers. Finally, it includes identifying, developing and disseminating information on the use of technology to train supervisors of direct support workers cost efficiently.

IV. STUDIES OF EFFICIENCY AND PRODUCTIVITY IN HUMAN SERVICES

Low direct support worker wages are a serious impediment to the quality and stability of Minnesota's human services system. It is crucial to underscore the importance of wage support from the Legislature to the future of Minnesota's service system. But it is equally, if not more important, for Minnesota to increase the efficiency of its human service system and the productivity of its workforce. Minnesota can no longer simply accept the use of inefficient models of care and their forced unproductive staff requirements as part of the cost of daily business in the Federal Medicaid program. Just as the Alliance for Consumer Options seeks to partner with the Legislature to provide decent wages to staff, it is important for the Legislature to partner with the provider community to identify inefficiencies and ways to increase productivity that can help pay for increased wages to direct support workers. Examples of strategies to accomplish this are outlined here.

1. Examine the cost implications of current recruitment and retention outcomes.

    Staff recruitment and retention challenges are very costly. Ongoing research is needed to identify the costs and benefits of various interventions to address these challenges. Such an analysis may find that systemic efforts that reduce advertising, recruitment, hiring, and training costs for new workers, and the costs of overtime and temporary services to cover open positions could free resources to reinvest in long-term highly skilled workers.

2. Examine cost efficiencies possible within the current service delivery system.

Several strategies might be used to identify and implement changes to achieve cost efficiencies. One example is the performance-based contracting demonstration now being piloted in a few Minnesota ICFs-MR. Only three states have higher Intermediate Care Facilities [for people with] Mental Retardation (ICF-MR) utilization rates as a proportion of state populations than Minnesota. Several states that once had substantially greater ICF-MR utilization rates have converted or are planning to convert much of their capacity to the Home and Community Based Service Waiver program (e.g., Colorado, New York, Massachusetts). In the Performance Based Contracting Demonstration, agencies providing ICF-MR services accepted a 5% reduction in their ICF-MR program rates to participate and operate by person-centered outcome standards. Examining the areas in which these agencies reduced funding could provide an opportunity to extend greater efficiencies to the community ICF-MR programs currently proving services to 900 people with developmental disabilities in Minnesota.

3. Examine direct support worker roles.

    Direct support workers fill many critical roles within the agencies and settings in which they work. Some of these roles require greater skills and competency than others. Distinctions of these various roles across agencies and target populations may provide useful information on how to build career pathways and incentives for people to stay in the field.

4. Consumer directed services.

Providing consumers with the opportunity to control their own services may be one way to provide efficiencies and to address the labor shortage for both public and private sectors. Providing individual consumers and their families the opportunity to recruit, train and keep direct support workers may build needed efficiency. Studies and demonstration projects to explore these options should be funded.

5. Work with the DD and/or Mental Health (Managed Care) Pilot Projects to develop efficient personnel practices.

Several counties or regions in Minnesota are working hard to develop system reform initiatives related to funding for long term care services for people with disabilities. This activity would work with the local workgroups for these pilot projects to develop, implement, and evaluate personnel policies that help direct support workers to carry out their new responsibilities.

References

Governor's Planning Council on Developmental Disabilities (1987).A new way of thinking. St. Paul: State of Minnesota, State Planning Agency, The Governor's Planning Council on Developmental Disabilities.

Governor's Planning Council on Developmental Disabilities (1992). Minnesotans speak out: A summary of town meetings held throughout Minnesota on developmental disabilities issues. St. Paul: State of Minnesota, State Planning Agency, The Governor's Planning Council on Developmental Disabilities.

Hafdahl, R.P. (1995). ARRM wage and benefit survey: Direct care staff in private community residential services serving people with developmental disabilities. St. Paul: Association on Residential Resources in Minnesota.

Jaskulski, T. & Ebenstein, W. (Eds.) (1996). Opportunities for excellence: Supporting the frontline workforce. Washington, DC: President's Committee on Mental Retardation.

Kilborn, P.T. (1994). A nation at risk: The imperative for educational reform. Report of the national Commission on Excellence in Education. Washington, DC: US Government Printing Office.

Larson, S.A. (1996a). 1996 Recruitment issues for residential and vocational agencies serving people with developmental disabilities or severe and persistent mental illness in Minnesota. Minneapolis: University of Minnesota, Institute on Community Integration; St. Paul: Alliance for Consumer Options.

Larson, S.A. (1996b). Influencing staff recruitment and retention: Personnel practices and facility characteristics. San Antonio, TX: Paper presented at the 1996 Annual Meeting of the American Association on Mental Retardation.

Larson, S.A., Hewitt, A., & Lakin, K.C. (1994). Residential services personnel: Recruitment, training and retention. In M.F. Hayden & B.H. Abery (Eds.) Challenges for a service system in transition: Ensuring quality community experiences for persons with developmental disabilities (pp. 313-341). Baltimore: Paul H. Brookes.

Larson, S.A. & Lakin, K.C. (1992). Direct-care staff stability in a national sample of small group homes. Mental Retardation, 30, 13-22.

Nichols, M.J. (1993). State technical college task force on educational opportunities for developmental disabilities service providers. St. Paul: Minnesota State Technical College System.

Prouty, R.W. & Lakin, K.C. (1996). Residential services for persons with developmental disabilities: Status and trends through 1995. Minneapolis: University of Minnesota, Research and Training Center on Community Living, Institute on Community Integration.

Research and Training Center on Supported Employment (1995). Preliminary comparison of national supported employment data for fiscal years 1991 to 1993. Richmond, VA: Virginia Commonwealth University.

a comprehensive workforce development plan for human services workers Taylor, M., Bradley, V., & Warren, R. (1996). The community support skill standards: Tools for managing change and achieving outcomes. Cambridge, MA: Human Services Research Institute.

a comprehensive workforce development plan for human services workers U.S. Bureau of the Census (1994). Statistical Abstract of the United States 1994. (114th Ed.). Washington, DC: Author.