"Are you gonna be here tomorrow?" A long-term view of direct support professional shortages in residential services. (Workforce).

"Why are you doing this? Employees are a dime a dozen!" That's what an administrator said to me in early 1980. I had just proposed a career ladder aimed at reducing staff turnover at the residential agency where I worked. I spoke far too soon, because turnover was not considered a problem then. It is now. Today the issues around recruiting and keeping quality direct support professionals (DSPs) have reached at least a near-crisis stage, if not much more than that.

Direct support staff in residential programs were turning over at an alarming rate: 50 percent per year. We hired replacements in bunches. Orientation programs ran constantly. Residents in our group homes frequently asked me and others the telling question: "Are you gonna be here tomorrow?" All too often the answer was "No."

I had a simple proposition: My idea was to try to staunch the hemorrhage by offering career opportunities. Looking at service trends in 1980, I guessed that we would need more direct support people. Community-based services were expanding as institutions closed. A report from the state demographer indicated that the Baby Boom children were moving past the age at which they would accept entry-level positions, unless there was some expectation of future promotion. There would be fewer entry-level direct support staff available over the next several years. We were hiring new people at a record pace, but we were not keeping them. I thought that if we could develop a strategy to keep our current and new employees, and if we could continue to hire new ones at the same rate, the agency would derive a double benefit: full staffing, plus a core of experienced people to train and supervise the new hires.

The idea did not go over. I presume the reasoning was that it was more cost effective to continue the status quo. The salaries of "older," more experienced employees increase steadily. On the other hand, having a majority of entry-level employees at entry-level wages would help keep costs down. I am not sure if this was a deliberate strategy on the part of the service-providing agencies, but the effect was the same. High wages have never been paid to DSPs in the MR/DD field. This is still true today. Turnover remains the same--often at 50 percent annually--if not even higher in some places.

Unfortunately, the problem of recruiting and keeping dedicated and capable staff goes back a lot farther than my own dim recollections. A summary report in 1947 said that a "patient" would find conditions inside the state hospital not much different from those from 20 years earlier, perhaps even worse. Buildings were in disrepair. Pay was low. Staff turnover was epidemic. "The result is a shortage of personnel, which falls more than 50 percent below minimum standards of good treatment." The report complains about the failure of the institutions to meet minimum standards for treatment, personnel, hygiene requirements, suitable food, and adequate clothing.

TRYING TO EFFECT CHANGE

As I pondered my own efforts to solve the recruitment/retention problem in 1980, a group of researchers, funded by the Bureau of Developmental Disabilities through what was then the Department of Health, Education, and Welfare, was considering the same thing. A national survey by Dr. Robert Bruininks and others investigated management problems in community residential facilities. It identified various difficulties. One of the highest-ranked problems was "Personnel issues, including recruitment, retainment, and development of staff."

Undaunted that my employer dismissed the idea, I proposed the idea of a career path on my own. I talked about it at the American Association on Mental Retardation in 1980 and 1981. In essence, my plan was to lay out a curriculum of required and optional training events that would today be called competency-based. As direct-service employees completed the lower-level competencies, they would receive a small pay increase and be permitted to participate in more sophisticated training and development events of their own choice. Direct support staff would be labeled "Level 1" and "Level 2." After attaining Level 2, they could move to specialty areas within the residential program. For example, one person might, through this program, become the agency's recreation and leisure specialist or a behavior specialist. In addition to utilizing her skills internally, the agency might "rent out" the specialist to other agencies as a consultant, splitting the earnings with the trained employee-expert. Obviously, my goal was to enhance the prestige of the direct-service employee and provide incentive to develop skills useful programmatically and financially to the agency, yet develop loyalty between the parties at the same time.

It may have been naivete, but I really thought the idea would catch on if I talked about it enough to enough people. I gave talks at conferences and meetings. I held training sessions on career development, using the work of Richard Bolles, the author of the popular handbook, "What Color is Your Parachute?" Individual direct-service employees received the speeches and training sessions enthusiastically. But the situation of turnover continued. Eventually, I devoted my time to adding to my own expertise in the training and development field. It still remains to be proven whether a career development system will aid in recruitment and retention of direct-service staff.

Throughout the 1980s and into the 90s, myriad services and supports evolved as thousands of individuals with disabilities left institutions and found places to live in the community. Even though turnover rates continued to be high, service providers managed to find enough staff to initiate and carry on supports and services--somehow.

It is my intuition and that of many others that people with disabilities thrive when they can count on long-term relationships with their caregivers. Conversely, I believe that caregivers thrive when they can anticipate being able to "grow" professionally after they have gained experience in direct service. This experience gives them authority and prepares them to be role models for those who would follow them.

Today we have reached a crisis point. In several parts of the country, even more new service models under Medicaid waivers and other funding sources are emerging. States are releasing dollars to end waiting lists and provide services. Some new rules specifically require increases in DSP pay levels, yet vacancy and turnover rates are critically high. The people to do the work may not "be here." They have to be considered worth a lot more than "a dime a dozen" if they are going to be here tomorrow.

David C. Pfriem is Executive Director of the Center for Mental Retardation (CMR), a member agency of The Arc. Mr. Pfriem has been involved in services for people with mental retardation and developmental disabilities since 1974. Much of his work has involved staff development and training. He and his spouse live in Lakewood, OH, and are the parents of two adult children.