“If I had only one sentence, this would be it: Direct support work is a highly skilled job,” says Amy Hewitt.

“It’s not viewed that way by society – or, frankly, by many employers – but not everybody can do this job. You have to be smart; you have to be able to problem solve; you have to be flexible and a quick thinker. You also need patience and empathy and creativity. We’re not going to get anywhere in terms of policy advocacy or getting the supports we need in place without clearly articulating that this is a highly skilled job.”

Hewitt is a senior research associate at the University of Minnesota’s Research and Training Center on Community Living. The center’s mission is to support community living for people with intellectual and developmental disabilities – and that has led to a focus on strengthening and supporting the direct support workforce.

“The quality of people’s lives is directly related to the quality of the support that they get, and that support is provided by direct support workers,” says Hewitt. “So a lot of our work is in trying to understand workforce challenges – and, more importantly, trying to develop tools and resources for community providers, to help them improve their retention rates and the competence of their workers.

“Direct support work is not just about keeping people clean and fed and safe. It’s about helping them make friends; helping them evolve relationships; helping them decide what activities in the community they’re interested in and connecting them to those supports. It’s about helping them have a life.”

To improve clients’ lives, you need to reduce worker turnover
The center’s research into the workforce is based on “the premise that people’s lives are better if they have a well-trained and stable workforce, so if you can reduce turnover you can improve lives,” Hewitt explains. “We did a fairly comprehensive study in Minnesota that showed that people who received care in organizations with higher rates of turnover had worse outcomes.”

Hewitt’s colleague Sheryl Larson have conducted a longitudinal study of direct support workers that Hewitt calls “seminal,” interviewing them when they were hired and then again over the course of a year to learn why so many left their jobs within three to six months. Common reasons for departure included:

• Poor wages and benefits;
• Limited, nonexistent or inefficient supervision;
• Conflicts with coworkers; and
• Not having understood what the job entailed when they signed on.

That study led to what Hewitt calls “applied, or intervention, research.” In several studies, Hewitt and her colleagues have tested various interventions aimed at improving those problems to see if they affect turnover rates. The findings, she says, are encouraging: “More and more, our work is showing that organizations can change behavior, culture, and practice in a way that will benefit the workers.”

What employers can do
“Wages and access to benefits really matter. We would be remiss not to say that,” says Hewitt. “But that said, there really are things that organizations can do differently now, without more money, just using the resources they have more wisely, that can change the turnover outcomes within their workforce.

“That’s often very hard for providers to accept, that they create environments in which workers feel devalued, feel incompetent, feel disrespected, and there are things they can do to improve.”

Strategies the center teaches to employers include:

• How to identify and hire the right people for the job, rather than hiring “whoever walks through the door”;
• Realistic job previewing, a technique designed to ensure that people know what the job entails before signing on to do it;
• Effective supervision, through the use of the coaching supervision model and other strategies; and
• Empowering direct support workers by including them more in decision-making.

Sharing knowledge about the workforce across settings
The research and training center is also sharing what it knows about improving direct support jobs through the National Direct Service Workforce Resource Center, a project of the Center for Medicare and Medicaid Services. Hewitt’s group is one of three organizations selected (the others are PHI and the Institute for the Future of Aging Services) to provide technical assistance to states that are strengthening their home- and community-based direct care workforces.

“We help states either develop policy or programs or improve their understanding of workforce issues,” Hewitt says of the technical assistance providers. “And we spend time together as kind of a think tank. Our time together and our reporting has solidified our understanding that a lot of our issues are the same across the various sectors — intellectual and developmental disabilities, behavioral health, aging, physical disabilities, etc.”

The TA providers are also working on developing a set of recommendations for how to strengthen the direct-care workforce across all home- and community-based settings. As the background for those recommendations, Hewitt and her colleagues from the DSW Resource Center are writing a comprehensive literature review of “what is known about the workforce across the behavioral health, aging, intellectual and developmental disabilities and physical disabilities communities.” The paper, which is due out in late August, will be available at the DSW Resource Center website.

Primarily, the things that we struggle with are similar
In the past, providers and researchers in the field of aging services and physical disabilities rarely mingled with their counterparts in the intellectual and developmental disabilities or mental health fields. Hewitt is glad those days are coming to an end. “We would all do better if we communicated more across the sectors, if we shared ideas and resources,” she says. “From a policy point of view, there are benefits in coming together with a single message from a policy advocacy point of view from across all sectors – and I mean mental health as well.

“Unfortunately, services tend to follow funding, so as long as the funding sources for the different services are doled out from separate silos, the idea that all direct-care workers will be trained the same and treated the same is not realistic.”

The silo effect is “absolutely” the main cause of the disconnect, Hewitt believes, but there have also been significant differences in the way services were delivered. She sees those differences blurring as services for the aging and people with physical disabilities become more home-based and person-centered, catching up to a trend that started about 20 years ago in the intellectual and developmental disabilities field.

Once you’re delivering home- and community-based care and tailoring it to individual preferences and needs, workforce issues tend to converge regardless of what kinds of clients you’re assisting. “Primarily the things that we struggle with are similar: the logistics of finding enough workers, giving them enough hours, getting them where they need to be, getting them trained.”

Another change in aging services that has brought the silos closer, she says, is “the realization that you need an additional skill set and different levels of care to work with people with who have unique needs, like Alzheimer’s.” Many people with intellectual and developmental disabilities who receive long-term care need special assistance in dealing with “challenging behaviors – things like self-injurious behavior, property destruction, responding emotionally to stimuli in a way that is not typical. That’s similar to what can happen with Alzheimer’s,” she notes.

We need to support relationships between workers and the people they assist…
One of the most important things she has learned from her work, Hewitt says, is that “effective direct support is about relationships. I think we try too hard to objectify the work and to put barriers between the relationships. But in the end, it only works for the client if there’s a positive relationship. And if you ask workers why they stay, despite all the barriers — the low wages, the lack of benefits, the often bad or nonexistent supervision, the organizations that don’t respect them — the reason is their relationships with the people they provide support to.

“We have direct support workers who have been working for the same clients for 20, 30 years. These are lifelong relationships that result in those people having better lives. Yet we try to build policies and procedures that deny those relationships.

“I get that employers have to be concerned about liability, but if we stopped hiring people who shouldn’t do this work, we wouldn’t have to worry about that.”

… and we need to support families better
Of course, finding enough of the right people is not always easy – and it will only become more of a challenge as more people need services –unless significant changes are made. “I think we have to make the jobs more attractive, certainly, and do better at reaching out to other pools of potential workers,” says Hewitt. “But at the same time, we have to figure out how to give more support to families who deliver services, so they don’t go bankrupt or become emotionally and physically depleted.

“I think that’s what consumer direction is about: trying to figure out how to get people the support they need within the context of their natural family.”

Interview by Elise Nakhnikian, Senior Online Editor
enakhnikian@phinational.org