Impact Feature Issue on Direct Support Workforce Development

California, like many other states, faces a staffing crisis due to poor conditions of employment for workers who provide direct support to individuals with disabilities in community settings. A reliable, committed, and professional direct support staff is critical to developing “person-centered” services that help people to lead self-directed lives in integrated settings of their own choosing. This article addresses the specific roots of the staffing crisis in California and a new initiative to overcome it. The initiative includes the creation of a new non-profit social enterprise, called the Consumer Directed Services Network (CDSN), designed to provide a comprehensive package of recruitment and training supports to multiple provider agencies. In addition, the new initiative has put forth a policy proposal to improve compensation for workers in agencies that meet specific training benchmarks. The initiative supports building a political partnership among organized labor and parts of the provider and advocacy community to support policy reform.

The Workforce Crisis in California’s Community System

California’s community services system assists more than 200,000 people with developmental disabilities, employs approximately 90,000 workers, and costs over $3 billion per year. Developmental services in California have undergone a dramatic transformation since the 1969 Lanterman Developmental Disabilities Services Act recognized the civil right of people with developmental disabilities to determine their own life plans, places of residence, and service providers. The Lanterman Act created an entitlement to services, and established a community-based system operating under the principles of decentralization and local community control. Over time, a steady progression of federal and state legislation, court decisions, and Medicaid Home and Community Based Services (HCBS) waivers have facilitated the development of flexible and innovative programs in the community system.

As a result of this transformation, services that once were delivered by large, segregated public institutions now operate through private nonprofit and for-profit community-based agencies. This dramatic change in the type of entity that provides services has had enormous and often unforeseen consequences for the direct support workforce, for employee-employer relations, for the level of training and professionalization of the workforce, and for other aspects of the direct support labor market. Four consequences are of particular importance:

• Poor wages and benefits. Dismantling the state system of institutional care turned public-sector, unionized jobs with health insurance, pensions, training, and career ladders into poorly paid jobs with fewer benefits and even fewer opportunities for career advancement. The labor standards that exist in public sector and/or unionized jobs do not exist in private labor markets, and agency reimbursement rates are determined based on the going wage for low-skilled workers. Simple mechanisms such as cost of living adjustments that are built into public sector contracts or collective bargaining agreements are absent, as is access to state-administered health insurance and retirement benefits.Poor compensation is recognized as a main cause of the extremely high rates of turnover. High turnover forces providers to struggle to find qualified workers, undermines training, continually disturbs relationships between workers and people with disabilities, and ultimately undermines quality of care.
• Changing job descriptions and lack of training support. DSPs providing person-centered services designed to maximize self-determination have very different job responsibilities than workers in institutions and traditional services. While the latter work under the direction of on-site supervisors in structured and routinized programs, workers providing person-centered services perform a broad array of tasks autonomously as they help people with disabilities lead self-directed lives. For example, they provide medication supports; implement behavioral plans; teach new self-care skills; assist people with disabilities in navigating relationships with family, neighbors, co-workers and others; advocate for their rights; teach self-advocacy; and interact in many different work, home, and social environments. Workers in person-centered services are accountable not only to their employers but to people with disabilities and families, who play a significant role in hiring, supervision, and possible termination.California’s community-based developmental services system has not invested in training for direct support workers in these new services. Moreover, it has not tapped into the state’s workforce investment system nor its community college system, the two major sources of funding for workforce training and education. Instead, community agencies are held responsible for providing training to their direct support staff, but they have limited capacity to design or deliver this training.
• Proliferation of employers. The shift to a decentralized community-based system resulted in the creation of 8,000 community-provider agencies, with an estimated average employment of fewer than eight full-time-equivalent workers. In many cases, agency directors value small agency size because they associate it with a higher quality of personalized service and responsiveness to local needs. In fact, decentralization and community control are core values of California’s service system. The proliferation of small agencies also has some drawbacks, however. Small agencies often lack business expertise and face high administrative costs. Healthcare insurance, which is one of the keys to retaining workers in this industry, is cheaper with a greater number of workers in the health insurance pool. In addition, the smaller agencies provide only minimal on-the-job training for their workers and are unable to provide career advancement opportunities. These inefficiencies absorb resources that could otherwise be used for service provision. Decentralization in California has meant that the staffing crisis, which must be addressed on a multi-employer or sector-wide basis, has been severely neglected.
• Families as employers. In California, more than 30,000 families now directly hire workers to provide respite, daycare, and other services, and another 9,000 people with disabilities will be eligible for self-directed service vouchers over the next three years. Evaluations have shown that people with disabilities who are able to choose and arrange their own services and personnel have shown an overall increase in measures of satisfaction and quality of life because of their increased flexibility and choice. Although increased choice has had positive results for the families involved, it can create difficulties for workers, who experience greater difficulty finding work, often receive no Workers’ Compensation insurance coverage, and rarely have access to health insurance, training, or career advancement. Although many of the people who provide these services are family and friends who may not need this level of workforce supports, others are trying to make a living doing this work and want to stay in the field.

States are drawing from a growing set of best practices in pursuing a range of strategies within these programs to improve the recruitment and retention of their direct support workforce, such as:

• Offering better employee benefits, including health care.
• Providing enhanced training for Direct Support Professionals (DSPs) and supervisors.
• Creating opportunities for professional development and advancement.
• Recognizing and rewarding performance of individual workers and of employer agencies.
• Implementing more effective recruitment and selection strategies.

A Strategy for Change

Absent state action to address the staffing crisis on a sector-wide basis, creativity and innovation have emerged from the bottom-up. The Consumer Directed Services Network (CDSN) has initiated a new strategy that combines the creation of infrastructure to help agencies recruit and train workers, a legislative proposal that creates funding for compensation increases tied to training, and outreach to promote positive relationships among stakeholders, including organized labor, for policy reform. Components include the following:

• CDSN: Creating the infrastructure for workforce development. The CDSN is a non-profit organization that offers services to agencies providing person-centered services to people with developmental disabilities in California. Incorporated in 2006, CDSN is now poised to launch as a financially self-sufficient enterprise. CDSN is designed to help small and medium-size agencies address their workforce issues by providing administrative and workforce development services while preserving the autonomy of agencies and people with disabilities over all aspects of service delivery. The CDSN’s services include payroll, tax compliance, recruitment, and staff training. This investment in a multi-employer training infrastructure is made possible through foundation grants, agency fee for service, and will eventually tap into public training and education funds that have not been previously used in this sector.
• Legislative reform: Using rate reform to create incentives for stabilizing and professionalizing the workforce. CDSN sponsored legislation (AB 1427) in 2007 to allocate funds for rate increases for agencies that met specified benchmarks for training their workforce. The bill was passed by the legislature, but was vetoed by Governor Schwarzenneger. The bill garnered the support of major consumer advocacy groups and SEIU, and sets the stage for future efforts to fund training linked to improvements in worker compensation.
• Partnerships for power: Uniting the political voices of people with disabilities, families and advocates, agency providers, and labor organizations. CDSN seeks cooperative relationships with all stakeholders, including organized labor, because convincing policymakers of the importance of passing this type of legislation will require joint stakeholder advocacy. In the past, the voice of workers has been absent in policy debates in this sector, which has weakened the potential for rate reform significantly. Since CDSN seeks to promote a worker voice in this industry, it requires that agencies receiving its services remain neutral if their workers seek representation from a labor union.

Conclusion

The disability rights movement calls for services that promote self-determination, community inclusion, choice, and independence. Achieving this goal will require continuing commitment and innovation. The CDSN initiative is a comprehensive strategy for stabilizing and professionalizing the direct support workforce that has great promise to not only improve the lives of the direct support workforce, but also the lives of the people with disabilities it supports.