Moving To Outcome Based Support Services
NOTE: The following is an excerpt from a personal communication with
Andrea Erickson, Executive Director of Project Independence in Costa Mesa,
California. In that letter, she outlined how her agency has successfully
moved towards an outcome based support service.
BACKGROUND. Project Independence began in 1977 as a pilot independent
living program providing time limited training in a supervised apartment
setting. We quickly changed to a continuum model using different levels
of training and support as well as separate funding rates. We also started
a Supported Employment program in 1986. We had to perform a constant juggling
act to provide services that actually helped people within the constraints
of an outdated model. That challenge, rapid growth and a decade of experience
helped us decide that we needed to view services in an entirely new way.
DEVELOPING OUTCOMES. In 1989, we implemented a quality assurance
process that became the foundation for an outcome based evaluation system.
Our primary focus was individual quality of life. We adopted the Outcome
Policies from Options (in Madison, Wisconsin) and we developed indicators
to measure each of the outcomes. We completed an annual Quality of Life
review with all of the individuals we support that addressed income, housing,
relationships and more.
STRATEGIC PLAN. Our strategic plan came next. We identified two
major outcomes for the agency:
1. The best, most innovative services available. Our first step
was to define the terms best and innovative. Next we established minimal,
objective and optimal standards for all of our program services : ILS, Supported
Employment and Community Based Day Services.
- We developed indicators which included: Quality of Life results, consistency
of service plans to futures plans, consistency of actual services to stated
individual preference, individual income & job retention etc. These
are still evolving as we focus on what is really important in the lives
of the individuals and families we support.
2. The best, most creative staff. We followed the same process.
- We developed indicators which included: education, performance, turnover,
employee satisfaction etc. These indicators continue to evolve.
Our next step was to tie our job descriptions directly to the results and
standards. In addition, staff performance (and salary) was linked to standards
and to individual outcomes.
Outcome standards for agency leadership and business practices were established
that supported our service and personnel standards. We were all very enthusiastic
during the development of standards because it was an opportunity to focus
on what we wanted to accomplish. Implementation was much more difficult.
We experienced internal and external challenges through this period.
- For example, we were still required to use a deficit model in developing
individual objectives rather than desired results. These focused on skill
acquisition instead of the support necessary to keep someone working and
living in the community. We have since entered into a performance contract
which provides consistency between actual services and the plan.
- Staff were reluctant to give up control. Some advocated "throwing
individuals out" rather than seeking new solutions. Some staff lacked
the self confidence to do problem solving.
- Many staff were threatened by increased accountability. The Quality
of Life and Quality of Service review process directly links staff performance
to our outcomes. Families and individuals are also surveyed for satisfaction.
Keeping staff focused on outcomes and their meaning can be a challenge.
- Finally, we had to invest time, money and staff into developing and
maintaining the systems to train staff, collect data and utilize it.
WHERE WE ARE TODAY. Each individual has a futures plan prior to starting
services. The working service plan (we call it the Key Action Checklist)
details the necessary actions needed to achieve the Futures Plan. We analyze
the Quality of Life of each individual using key indicators.
We follow the same process for all agency key results (e.g., community and
business). We develop monthly and quarterly reports so that recommendations
and problems are addressed immediately. In addition, all results are summarized
annually. This report serves as a needs assessment for new services, a report
card for the agency and provides us with important staff performance data.
We feel that the benefits of outcome based services have been many:
- Staff know exactly what is expected of them and can measure their own
performance. Staff burnout is lessened because their contributions are apparent.
- It focuses on accomplishments rather than on fixing individuals. Staff
have more clearly defined roles that are supported by the Quality of Life
and service standards.
- It provides a direction to the agency because it identifies what needs
to be done to really support the people we serve.
- Support circles and individuals are increasingly aware of what they
can expect. Individuals decide what they want and staff help them find the
tools to get there.
- Last, it promotes team building among the support circle, individual
and the agency. We may disagree on a method but we can't disagree on the
quality standards and the mission.
Supporting Support Staff =
Quality Personal Assistance
By Suzanne LeBaron, Personal Assistant Coordinator
Becoming Independent, Santa Rosa, CA
For a Becoming Independent (B.I.) Personal Assistant (PA), the job duties
vary as much as the individuals that our agency serves. Some PAs are live-in
roommates providing basic support in health and safety, while others provide
more extensive support through cooking, home maintenance, grocery shopping,
exercise programs, and some times through modeling good parenting skills.
The majority of our PAs provide some combination of intimate personal care
and more traditional "attendant" services. At present, we employ
about 45 PAs. Some are full-time employees with benefits, others work as
few as six hours per week. This does not include those people assisting
individuals who work only for In Home Supportive Services (I.H.S.S.).
As our supported living program has grown, we started to grapple with a
multifaceted concern: How do we bring this diverse group of employees into
the B.I. "family,'' make them feel welcome and supported, provide them
with useful professional training, and respond to our agency's liability
concerns? For employees who work in other B.I. support services, there
are many things accepted as "givens.'' For example, a tremendous amount
of peer support and advice, service review sessions, and regular staff meetings.
However, our PAs typically work on their own with minimal supervision and
support. This can lead to high levels of burnout and turnover, not to mention
our agency's well founded concern about training and liability.
In order to confront this concern, I started working with a consultant (Carol
Connelly) to develop a curriculum that would meet the agency's needs as
well as the support needs of our PAs. Regular training classes for PAs
began last fall (1995) and have included health and safety information,
in-depth training on Adult Protective Services and special incident reporting.
We've also tackled philosophical issues such as identifying caregiving styles,
recognizing burnout, examining what creates barriers to good caregiving,
and active listening. This is paid training time, in addition to the other
training that all B.I. employees receive.
Some of the most popular classes have included interactive activities designed
to help PAs feel what it's like to be on the receiving end of services.
While the classes are training sessions they also serve as an informal
support group for our PAs. During these sessions, our caregivers have the
opportunity to talk to other people who really understand and work together
on problem solving.
As our training and support program for PAs has developed, we also recognized
the need for a PA management program for the individuals we support. So,
in June we started a five week class titled "How to Manage Your Personal
Assistant Services" which focuses on developing communication skills
and reducing friction between recipients, and givers, of care. It's taught
by myself and a team from a local advocacy organization (Citizens Advocacy)
which includes Ross Long and Kathy Patterson (who received a grant to develop
the curriculum). The curriculum for the class deals with the technical
aspects of managing PA services (e.g., how to assess your needs for a personal
assistant, being a successful manager/employer}. In addition, several of
the classes parallel the PA class and deal with topics such as defining
caregiving styles, understanding boundaries, barriers to good caregiving,
recognizing burnout, and active listening. The last class in the series
is open to both individuals and PAs for a practice session in active listening
and an open discussion.
Robin Wright (the woman whose desire to live independently started us on
the road to supported living) says that she has found the classes helpful
and the curriculum right on target. Kathy Kirk, her daytime PA, says the
training program has helped introduce her to "things that make you
think about different kinds of disabilities, about getting too involved,
and recognizing different kinds of care - this stuff has helped."
Person to Person
Note: This is an excerpt from the Director's Report, Colorado Division
for Developmental Disabilities, Volume 3, Number 1, Fall, 1992.
Recently in France, a sheltered workshop asked its employees with developmental
disabilities to volunteer to assist in the design and administration of
a questionnaire to all other employees (Velche and Baysang, 1992). 51 individuals
with mental retardation volunteered and 40 completed training on survey
techniques and conducted surveys. These volunteers interviewed 355 individuals
with mental retardation and successfully collected information regarding
what adulthood meant to them, their feelings about roles, rights, duties,
and rules in life and at work, meaningfulness of work, and other subjects.
The results of this survey were used to develop revised rules for operation
of the workshop. The benefits of the approach were:
- "Peer to peer interaction resulted in a better reciprocal understanding,
a greater freedom of expression, and a discussion of more intimate issues",
- Persons most likely to speak out learned to collect opinions of others
so they might represent them or understand them in the future,
- Persons could see they had a voice and that it counted, and
- Costs for collection of the information were reduced from what it would
have cost to hire professional surveyors.
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