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Heike Boeltzig-Brown
Avenues Supported Living Services of Valencia, California was founded in 1997 by a husband and wife team, Scott and Lori Shepard. The agency provides supported living and community life engagement (CLE) services to individuals with intellectual and developmental disabilities (IDD). Key to Avenues’ success is a staffing approach that is grounded in client relationships. The agency limits staff hours to two shifts per week with the same individual.
This is done to facilitate client-staff matching and relationship building, but also to prevent potential burnout and frustration by ensuring both the clients they support and their staff have variety in their schedules. Avenues staff have expanded what they do by mentoring other agencies from within, thereby increasing service choices for individuals with IDD and their families. As of October 2016, Avenues provided CLE support to 26 individuals with IDD. Of those, 23 also received supported employment. Avenues does not have any supported employment funding per se, but provides job coaching in combination with individualized day services / CLE.
A focus on meaningful and productive activities guides Avenues’ CLE supports, which wrap around individuals’ work schedules. Examples of CLE activities include support with seeking and maintaining a job (paid or volunteer), enrolling in college classes or via adult education programs, and enrolling in recreational or hobby classes through local parks and recreation, the YMCA, etc. The approach lets clients gain exposure to new and preferred community activities, and provides structured support during times when the clients are not working. Clients can get up to 16 hours of CLE per day at a time that is convenient for them.
The amount 4 of support is based on a client’s individual needs. If a client needs less support during a particular activity, Avenues staff will start fading support for that activity. Scott Shepard provided the example of a client, Peter, who had been working in food services for over 20 years. Peter had a three-hour, five-day-a-week job. In the morning, Peter would go to Gold’s Gym, where he was a member. A staff member would help him choose and enroll in different classes. After having lunch, Peter would then work from 12:30PM until 3:30PM.
Avenues makes sure that in any given class, gym, volunteer job, or paid job, no more than 10 percent of the people there have disabilities. “When people are actively engaged with people that care about them and that they care about and have some places they call their own where they can see they're doing something meaningful and productive, their lives tend to be better, just like ours,” Scott explained. “So our mission is to help use that person-centered planning or thinking process to help people find connections and niches in our community that make sense for them.”
Staff have no more than two shifts per week with the same client. Avenues has found that, if a staff member spends too much time with the same individual, both the staff and the client tend to exhaust the relationship. The two-shift approach ensures that both clients and staff still look forward to seeing each other. This helps the relationship flourish. Avenues’ staffing approach also addresses the fact that staff take time off or go on leave. If one staff works five days a week with the same individual, and then takes a week off or goes on leave, the client’s routines change drastically.
In contrast, if a staff works with five different individuals (one each day), and he or she takes a vacation or goes on leaves, then each of those clients has only one day of their week disrupted. As an article from TASH puts it, “It is easier to create good matches between support people and people receiving support when the priority is not based on a person’s need to work a specific number of hours, but a person’s ability to fulfill the needed duties of the shift.” Avenues offers staff flexible work schedules, the total number of hours being subject to clients’ support needs and schedules. Avenues typically introduces newly hired staff to clients who have support hours available.
It takes time before a staff member can get into full-time employment, because they have to develop relationships with the individuals they support before increasing their hours. As of October 2016, Avenues has about 80 employees. Of those, 15 are roommates (i.e. they get paid to live with and support an Avenues client), and some of those also work with other people Avenues supports. Nine are middle management, and two are both roommates and middle management. About 15 other staffers are full time and the rest are part time, ranging from five to 30 hours a week. Some of the part time staffers are interested in more hours, but most are working the hours that fit their schedules.
During job interviews, Avenues leadership asks candidates about their interests and experience 5 to get a feel for which clients they may get along with. They then decide on the first individual to introduce a new staff to. Based on the training with that individual, leaders determine other people the new staff member may work well with. All staff are hired as employees (rather than contractors) and get benefits according to their status.
Despite pressure from funding sources to increase the number of clients, Avenues leadership chooses to remain a small program, serving no more than 20 clients. Adding more clients, in the Shepards’ opinion, would compromise the quality of services and supports that they provide. Avenues staff have expanded what they do by mentoring other agencies from within. The goal is that staff develop a relationship with clients and then branch off into their own agencies.
Supported living and CLE service providers in California actively share resources, ideas, and supports with one another, so mentorship was a natural way for Avenues to support the expansion of the provider community as well as increasing service choices for individuals with IDD and their families. “We hope that by nurturing new agencies to provide quality services, families will have real options and not be stuck with whoever has an opening,” said Lori. As of October 2016, Avenues has supported four staff members in creating their own programs.
Avenues was, itself, mentored into existence, and subsequently has mentored two other agencies. It has also assisted others in going through the process of becoming vendors. Each agency’s situation is unique and treated individually. In one case, the new agency directors had a lot of experience in providing services, but needed help on the business end. In another, the directors needed help in doing assessments and navigating the systems involved in service delivery. Some agency staff come to Avenues for help in writing up their service design or creating staff training modules, and others just want advice on a variety of topics.
Avenues has a good relationship with most of the other agencies in their area that provide similar services, since this is generally a non-competitive field. Avenues staff are currently working with a few agencies at various stages of development. It often starts with Avenues staff sitting down and going over a person-centered plan for the agency director. From there, the mentorship is customized. Some potential agencies do not go beyond this planning stage, while others continue to work with Avenues over time.
Using this staffing approach has enabled Avenues to keep staff turnover low. Retaining staff allows Avenues clients to maintain long-term relationships and trust. With that trust comes a willingness to try new things and take chances on other relationships. Lori noted that many former employees keep in touch with the clients they supported, even 10 years after they have left Avenues. Holiday and birthday cards are exchanged, and many staff even visit when they are in town. 6 Clients see staff once a week (instead of every day).
Different personalities work together in different ways, so a client can look forward to doing a variety of activities with staff who also enjoy those things. For example, one client may enjoy live concerts and work with a staff on Friday nights who also enjoys concerts. That staff may not be a good cook, so the client would not want to spend every evening with that staff. Variety in the staff schedule is good for staff as well. A staff can work with someone who needs a lot of physical support on Monday, a person who is non-verbal on Tuesday, a person who talks constantly on Wednesday, a person who needs a lot of emotional support on Thursday, and a person who is really active on Friday.
This variety helps staff to enjoy and look forward to each day. It also allows for administration to schedule staff to work with their strengths. A staff member who is a good cook can work five evenings with a different client each day, thereby positively affecting five clients. A staff who likes to work out or enjoys crafts or is a great organizer can likewise be valuable to five different teams. In contrast, if that staff works with the same client each day, it would get monotonous for both the staff and the client. “We all spend time with a variety of people and friends, engage in a variety of activities and get chores done in our own life. We try to ensure the people we support have the same opportunities,” said Lori.
Avenues limits staff time to two shifts per week with the same individual. The two-shift approach prevents potential burnout and frustration by ensuring that both clients and staff still look forward to seeing each other, which helps the relationship flourish.
Avenues recruits and hires staff with clients in mind. Effectively matching clients with staff is important for providing fully individualized CLE in combination with employment supports (job coaching). Giving both clients and staff a choice about who they would like to work with is key to successful client-staff relationships.
Scott Shepard, Executive Director: shepard6@pacbell.net
Lori Shepard, Director of Operations: avesls@pacbell.net
Website: http://www.avenuessls.org
Shepard, L. (2006, September/October). Opening New Doors Through Mentorship. TASH Connections, 32(9/10), 18-20.
Heike Boeltzig-Brown
Headquartered in a small rural town in northern Maine, Katahdin Friends, Inc. (KFI) provides community employment and life engagement supports, as well as home supports, to individuals with intellectual and developmental disabilities (IDD). KFI’s services extend throughout northern and southern Maine, including the cities of Portland and Bangor.
A flexible approach to staffing and support scheduling helps KFI ensure customized daily support schedules that meet individual goals. This approach also allows individuals to interact with a variety of direct support professionals, which is important for having a more engaged and meaningful life in the community.
As of July 2016, KFI supported 66 people with IDD through combinations of home, community, and work supports, and 28 people with a variety of disabilities in short-term job development funded by the public vocational rehabilitation program.
While most providers assign a group of individuals with IDD to each staff, KFI takes the opposite approach, assigning a team of three to five staff members to each individual. Because of this unusual staffing system, they are able to offer one-to-one support to many individuals at once via a rotating weekly schedule.
This means that one staff spends one to five hours with one individual, and then goes on to support another individual, sometimes in the same day. Other individuals have staff live with them at their home in revolving, 56-hour shifts. Support schedules are customized by day and continuously updated by KFI’s regionally based support teams to accommodate last-minute changes in individuals’ schedules, as well as any staff changes.
Using this flexible staffing approach was a natural outcome when KFI closed its center-based facilities and began supporting individuals in their homes and communities, says Gail Fanjoy, KFI’s CEO. Several KFI staff had different community connections that they could use on behalf of the individuals who they were serving. Staff used these connections across individuals to more deeply integrate them into their communities.
To ensure a flexible staffing arrangement, KFI staff need to be well versed in both employment services and community life engagement. “Our staff who work in these support schedules do everything,” explains Fanjoy. “They may be job coaching. They may be helping individuals connect in their community. They may be at a music jam in the evening, helping individuals to explore their love of music and entertainment.”
Forty-seven of KFI’s 84 direct support professionals are certified employment staff. While not mandated by the state of Maine, KFI expects all of their direct support professionals to take the College of Employment Services online training that incorporates the Association of People Supporting Employment First (APSE) nationally recognized supported employment competencies.
The direct support professionals that KFI hires need to be “joiners” who participate in their communities. Especially in the smaller, more rural communities, KFI staff know almost everyone, making it easier to connect community members to the individuals they support. KFI also looks for staffers who have proficiency with family engagement, and who understand the process of “person-centered thinking” and the concept of self-determination for people with IDD.
KFI prioritizes staff training and encourages staff feedback to make sure the goals of individuals with IDD are being met, and that those individuals are continually afforded full choice (including the occasional bad choice) in what activities they want to do. KFI has frequent staff meetings, pre-established quarterly goals, and required benchmark reports. Goals are intentional, but with a certain amount of flexibility when it comes to carrying them out. Direct support professionals together with their clients modify activities to meet individual goals and interests.
Staff flexibility allows for variation in each individual’s schedule, discourages prescriptive “programming,” and maintains KFI’s “person-centered thinking” ideals. Support providers become experts about each individual they support. This means that KFI clients have access to a range of supports based on their particular needs, up to and including 24/7 support in the home.
Individuals respond well to the rotating staff perhaps because this staffing pattern more authentically represents how most people spend their days: with a variety of people rather than just one. Each staff member brings their own interests to the individual for them to explore. This makes the training and fading of staff easier, as each newcomer is surrounded by several familiar staffers who know the individual’s routine inside and out.
Transportation barriers are addressed as support providers use their own cars and are reimbursed for the miles. This allows for flexibility to mold to people’s busy schedules.
KFI staff appreciate the flexibility that comes with their job, allowing them to better balance family and work life. The amount of flexibility granted to a staff member increases with seniority on the job. Staff flexibility not only positively impacts staff retention but also works as an incentive to recruit new staff members, says Fanjoy.
Root all practices in a clear philosophy. KFI has a strong, philosophical approach in everything they do, including how their supports are designed and delivered. These values are manifested in every aspect of the organizational culture, from hiring, to training, to individualized and highly flexible supports.
Focus on individual experiences. For KFI, community life engagement is all about building experiences for people and creating opportunities for individuals to be engaged in natural settings. Their services do not involve person-centered planning so much as person-centered thinking throughout all aspects of the organization.
Cross-train staff for multiple roles. Staff need sufficient training to fill various roles, including providing home, community, and work supports.
Gail Fanjoy, CEO: gfanjoy@kfimaine.org KFI website: http://www.kfimaine.org Another KFI promising practice: “Making Mission-Driven Choices About Funding and Service Innovation”
Avenues Supported Living Services of California and Katahdin Friends, Inc. (KFI) of Maine implemented Guidepost 1 in an effort to individualize supports for each person. Use the sidebar on the left to read their stories.
The LifeCourse framework was originally developed by Missouri Family to Family, housed within Missouri’s University Center for Excellence in Developmental Disabilities Education, Research and Services (UCEDD) at the University of Missouri–Kansas City Institute for Human Development.
The Integrated Services and Supports worksheet is designed to help families and individuals think about how to work in partnership to support their vision for employment.
County Connections Initial and Annual Assessment is a very holistic assessment of individuals' network, goals, and needs, based on the LifeCourse categories. It gives a clear picture of any gaps that may be missing from natural and paid supports.
The Positive Personal Profile is a person-centered planning tool used by TransCen and other providers. It takes inventory of all of an individual's positive attributes as well as where they need support.
Use the sidebar on the left to access a selection of resources that promote Guidepost 1: individualizing supports for each person.
Originally published in 2017 as Engage Brief #4.
This chapter elaborates in detail Guidepost 1: Individualize support for each person and highlights examples of how this guidepost is being implemented by service providers based on expert interviews and case studies from outstanding providers of CLE supports.
Individualized supports were viewed by all interviewees as the central tenet to providing the highest quality Community Life Engagement to each person. As one parent stated: “First and foremost, I think anything you do for an individual has got to be individualized to them and their needs and their community…You always want to start with what the person is interested in.”
Individualization of supports:
starts with understanding personal preferences, goals, interests, and skills
emphasizes person-centered planning and discovery, and
requires creative staffing, intentional grouping, and at times generating additional funding.
“It's not a written policy, but it's part of our orientation and our culture. It's that everything is individualized. Everything is identified by the person and the settings that they want to be in.”
Individualization of CLE supports usually started from first contact with the individual. Interviewees described a process of sitting down with the individual (and often their family) to better understand who the person is, their likes and dislikes, and their visions and plans for themselves. This was an opportunity to listen and discuss how the provider can best serve their needs. As one parent recounted:
“When we initially met with the people here, they asked (her) a lot of questions about what she liked and seemed to really listen to that, what she didn't like. She's very vocal about what she likes and doesn't like. And it was nice to have somebody listen... And yet be willing to push her sometimes a little bit out of her comfort zone because that also sometimes, with her, needs to be done to try something new. And then if she didn't like it, you come back and talk about it."
Individualizing supports aimed to put the individual in situations they chose to be in, and in situations where they felt comfortable and could thrive. By customizing supports to each individual, providers avoided “programming” or, as one interviewee put it, “stuff(ing) people into activities.”
It’s also important to remember that individual preferences, interests, and skill sets change and evolve over time, so the need to keep asking and observing is paramount. As a result, the activities that an individual participates in should evolve as well.
Person-centered planning, Discovery, and other formal or informal planning processes help develop the individual’s goals and interests into activities that will eventually comprise daily and weekly schedules while still maintaining their personal choices. Many individuals can have the same goal, but how they accomplish each goal should be tailored to the individual. Maintaining a commitment to one’s goals is considered important. As one direct support professional said,
“And if we're halfway through the year and we're seeing maybe a goal isn't going well…say we have a consumer that has an exercise goal. …we try and convince them, "Your service coordinator really wants you to go. I mean this is one of your goals. Are you sure?"
"No, I don't want to do that." [So] we try and make it fun, "Well, how about instead of working out at the Y, let's just go for a walk at the lake." Or…"Hey, you want to go play basketball?"
One provider manager recommended that, for truly individualized results, the discovery process take place in the individual’s home instead of the provider’s office:
“It’s just an extension and an increase of a discovery that we used to do anyway here, but just more directed and has a structure... And it does help us even to look at places and look at things that we might not have taken into consideration, because it gives you direct tools….And you might not know that in their home they have all this stuff they’re very interested in that doesn’t come out somewhere else."
High quality person-centered planning and discovery and the gradual development of a CLE plan should first and foremost be based around an individual’s interests. As one parent explained, “You always want to start with what the person is interested in. If the person is interested in animals, go into animals. If the person's interested in photography, go to a local photography club and regularly attend their meetings.”
As interests reveal themselves and goals toward CLE begin to be developed, the individual can be introduced to opportunities and experiences that may be outside of their comfort zone. This can foster life skills or act as career exploration, as described by a provider manager:
“We do outreach to the volunteer sites… and we base it off of our client’s interests. Not only their recreational interests but also if they’re interested in like learning a certain skill or like data entry or maybe somebody wants to learn how to cook or something. We try to really ask them what their interests are.”
Sometimes an activity builds upon already discovered interests. At the same site, a direct support professional described how an individual’s interest in his Jewish heritage led to a new level of engagement:
“One of the clients in the program, his mother's Jewish, and he's very aware of his heritage …[and] we just restarted our connection to the Jewish Contemporary Museum. And as soon as he heard that.. he wanted to do it and come in on a Friday [when he’s never wanted to participate on Fridays before]. I was like, "Wow!" So it was good for me to hear that…it was connecting with people in something that's really important to them, and you make that direct connection.”
A common challenge is individualizing supports with limited resources. Some described strategies for managing staffing through creative approaches to grouping and scheduling individuals, re-defining staff roles, and finding and using funding. Each case study site had a slightly different approach and focus, but all were aimed at the same goal of maximizing individualization.
One case study site focused on 1:1 support from a specific staff member, as one direct support professional explained, “We try and keep it at one on one. I mean we try and keep it to where they have one staff person that they are familiar with and comfortable with and come to rely on a little bit.” While staff hours and individual’s funding sources and support needs occasionally made 1:1 prohibitive, staff-wide collaboration across all departments ensured familiarity with the individual so that their supports remained individualized. Another case study site offered individualized supports by having three to four staff members work with one individual throughout the course of the week based on the individual’s schedule. Rather than each staff member having a specialty, staff members were trained to support the individual in multiple roles from employment to non-work activities. Balancing these ever-changing schedules required collaboration and frequent communication in order to make sure individualized supports are maintained, as described by a manager at that site:
“I do all the schedules, and our schedule is color coded, if you can imagine nine staff and I believe 15 people that we support on a day to day basis. … I always call it a Rubik’s cube, so when you shift something everything else has to take that into account. And so it’s tremendously challenging because it’s not a 9:00 to 2:00… And so a staff person might be supporting you for a couple hours … and then might be supporting two people together throughout the day. They might have a four-and-a-half hour day or they might have a ten-and-a-half-hour day.”
And due to funding limitations, the third case study site supported individuals in groups led by one staff member. In order to keep supports individualized, however, these groups were organized based around the interests of the individual and their schedules, as described in the next section.
Purposeful grouping to individualize supports despite group staffing ratios was a strategy many interviewees discussed. Providers attempted to group individuals based on shared interests or friendships, as described by a provider agency administrator:
“So we have white boards around the office, where people say, “I want to learn to knit.” So we'll put knitting up there and we'll put the one person that wants to learn to knit. And then if someone else comes along and someone else, when we have a critical mass, we then go research that opportunity and find it in the community.”
Similarly, a direct support provider said, “When we have another staff that’s out doing the same [activity], we really try and meet up and do something together because, [many whom we support] have been lifelong friends... So we try to utilize the time we have together as well as possible”
While focusing on individual interests should be paramount, a provider manager spoke to the need for occasional compromise.
“Sometimes with the scheduling we’ve had to ask them to like compromise a little bit, but, for the most part, we want them to be doing what they want to do. And, yeah, I would say, for the most part, they really speak their minds and then we change their schedules accordingly. There is some need for us to maintain the schedules consistently because it gives us a better opportunity to work on those skills, but if they really hated something we would never make them go just because that’s what the group is doing that day.”
Maintaining individualization with limited funds for staff was another common problem addressed by providers. Two of the case study sites found creative methods to bring in new funds, such as using direct service staff to offer trainings or technical assistance to other providers looking to expand community-based supports. Said one administrator,
“We’re trying to look at how else can we bring funding in, and a lot of what we are trying to do is through our training contracts and utilizing the staff that’s doing the direct service here to do training and to use that to subsidize the fee for service rate, because it just isn’t covering it.”
To offset limited direct funds, one provider employed a strategy that braids funds. Developmental disability services funds were used to facilitate job exploration and skill building. Upon placement in a job, the provider then used vocational rehabilitation funds to offer job coaching. Day service hours gradually decreased as employment hours increased.
This strategy was approved by the regional developmental disability office, which saw cost savings from the provider absorbing the day support hours (with the idea that they will decrease as the individual becomes more independent) and using vocational rehabilitation funds to support employment. The strategy allowed staff to maintain their specialties, said an administrator:
“So the community instructors, we don’t pull them to job coach because that would involve scrambling these groups and we don’t want to do that, so the group day stuff is like set in stone and community instructors really focus on that element. And then our employment services people…do all of the work-related stuff.”
Another provider relied on a Medicaid program where provider boards and the Department of Mental Health match 40% of Medicaid’s contribution. For a $2,000 outlay, the provider then has access to $12,000 worth of preventative, community-integration services.
But even the $12,000 sometimes proves not enough. This provider also used small grants from county-based boards to supplement waiver funds for community integration services. These grants are given with no required designation, so the provider can use the funds for non-covered Medicaid services such as employment follow-along or for those who are not waiver-eligible.
This patchwork funding was part of the current financial reality facing the state in which this provider operates, making the need for early community integration all the more immediate. According to the agency director:
“…as you know, money is very, very tight…it used to be you'd make someone eligible, and you'd start throwing services at them. Now the philosophy is, you make somebody eligible, and you start helping them figure out how to do things on their own, without support, without paid support.”
However, most staff were committed to serving individuals with disabilities and understood the financial stress the provider was under. Said one direct support professional,
“You can spend a lot of time in a day doing stuff for people that you're not getting paid for… But our agency… we're focused on what the person needs. I mean, as long as it's realistic. If we have to drive across town to go do this [with] them or take them here or to get a resource, we're going to do in 99 out of 100 times. We're not going to leave a person hanging."
This section is part of a series of four guideposts, each expanding on one of the four Guideposts for Community Life Engagement. These briefs serve as a core element of the Community Life Engagement toolkit for states and service providers.
This section focuses on Guidepost 1: Individualize supports for each person. Community Life Engagement supports should be tailored to the interests and needs of each unique person. Individualization of supports:
starts with understanding personal preferences, goals, interests, and skills
emphasizes person-centered planning and discovery, and
requires creative staffing, intentional grouping, and at times generating additional funding.
Use the sidebar on the left to access an overview of Guidepost 1, two promising practices from providers that illustrate how to implement the Guidepost, and a set of additional resources for further consideration.