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Workload Standards Study 

Technical Report: Case/Resource Management in the Division of Developmental Disabilities

The client population in the Division of Developmental Disabilities (DDD) has grown in size and complexity without a corresponding increase in case/resource management staff. Caseloads had increased to 141 persons per case/resource manager in 1997, making Washington the state with the highest caseloads nationally. Some of the caseload changes leading to increased complexity are: inclusion of individuals with many more challenging concerns, such as mental health or community protection issues, and increased life span of people with developmental disabilities.

Adapting a previously successful research design used nationally in many workload studies of Children and Family Services, including Washington State, DDD funded a research project to be conducted by the Department of Social and Health Services (DSHS) Research and Data Analysis division.

Study Purpose:

• Provide a scientific measurement of current workload: how long it takes case/resource managers to provide community case management and community resource development and management services to clients of DDD.
• Develop a set of minimum/essential workload standards and of optimal/best practice standards for the provision of services in DDD both for case management and for resource management activities.
• Provide the tools for DDD to calculate staffing needs to fulfill essential and best practice standards and to project such needs based on estimates of caseload growth, the effects of policy changes and projections of unmet service needs.

Study Methods
A scientific time measurement of workload.

Four Week 100% time measurement: Case/resource managers participated in a four-week 100% total-time measurement split between two ten-day work segments involving logging all daily activities. Response rates were very high: 96 percent in November and 89 percent in April. Estimates were obtained for leave and administrative time, and service activities not directly related to individual clients, such as the development and management of resources.

Prevalence Survey of Complex Characteristics: Case/ resource managers also answered a prevalence survey about complex characteristics and situations of current individuals on their caseloads and about those not contacted at all during the previous year. They responded to a random sample survey of more than 10% of their client caseloads (about 2,700 persons statewide), regarding yearly contacts and the prevalence of certain complex characteristics and situations. These included diagnosed mental illness, high nursing care needs, involvement with the legal system, family coping problems and others. This survey provided the basis for the random sample and the over-sampling of the groups with special characteristics used subsequently in the one-month tracking. A very high response rate was obtained in this survey: 92 percent.

One Month Case Tracking: Case/resource managers were asked to participate in a one-month case tracking, logging all activities and times spent with a statewide random sample of DDD clients, and with an additional over-sampling of clients with complex characteristics and situations (February 1998). Again the response rate was high, even for this long, one-month, tracking: 82 percent. Detailed measurements were taken of time spent in case management activities supporting the average client, or specific groups of clients, in a variety of programs.

The Development of Minimum/Essential and Optimal/Best Practice Workload Standards

Essential and Best Practice Standards for Case Management: With the guidance of two national experts, a group of case/resource managers, supervisors and regional administrators, experienced in the field of developmental disabilities, developed a set of essential workload standards. As the group and the consultants methodically developed each essential standard for the typical caseload, they used the actual times and the activities done during the month long data collection as a basis for their decisions. They looked at the time actually spent and determined how much longer a modified set of activities should have taken in order to meet minimum/essential mandates and, additionally, to fulfill optimal/best practices.

• They listed the steps and activities that were minimally and optimally necessary to complete a process of support in a variety of programs.
• They examined how long each activity actually took and looked at which activities should be done differently, were not done long enough, or were not done at all.
• They determined for how many people and how often each activity should be done, both to meet minimum/essential standards and, for major programs, to meet optimal/best practice standards.
• They met again two months later to review the set of activities and overall times established for the phases in each program and to make any needed adjustments in light of requirements to meet essential legal and administrative mandates for essential standards.

Standards for Resource Management: A similar process was used to develop essential standards for a variety of resource management tasks, both for developing and maintaining such resources. However, due to the episodic nature of some of these tasks estimates of actual time spent had to be made using an expert estimation process.

The development of a calculation system for estimating staffing needs

Estimates were obtained of the proportion of work not being done by comparing current work time with the time required to fulfill essential minimum standards. An automated calculation system to produce overall staffing needs was generated by electronically linking such time differences across programs for a given year (1997) and a given population served.

Furthermore, automated projections of staffing needs were made possible by modiFiscal Yearing the parameters of the above calculation system: modiFiscal Yearing either the overall number of clients served, the composition of the clients or the mix of programs. These modifications were based on

• overall caseload growth projections,
• changes in particular programs due to policy or entitlement criteria,
• expansion of DDD-funded programs to address unmet service needs

Key Findings
Extent of Work Below Standards, Essential and Best Practice: In 1997, the work of 170 DDD case/resource managers was well below either essential or best practice standards in supporting 24,000 persons with developmental disabilities and their families.

• With caseloads of 1:141 they were able to fulfill only 45 percent of essential mandated work: 55 percent was left undone.
• If one considers not only essential but also optimal/best practice work, only 29 percent was being done: 71 percent was left undone

Comparison with Other States: The extent of the severity of DDD understaffing is also revealed when comparing Washington's caseload ratio with those of other states.

• Washington has the highest caseload ratio nationally (the national median was 1:40 in 1995).
• Washington has the highest caseload ratio among states similar to Washington in economic and demographic characteristics and in having a state operated case management system (the caseload average was 1:60 among the states most similar to Washington at the end of 1997, the same year as this study).

Work with Clients with Special Needs: This understaffing is further exacerbated by the fact that almost half of DDD clients have special needs in addition to their developmental disability, such as community protection issues, mental illness, language/cultural differences, and families with coping difficulties.

• Up to four times more time is spent with these persons than with the average person.

Types of Work Left Undone: Some of the consequences of this understaffing are:

• Most of the essential work is done to connect persons to needed services when the services are available (60 percent done), but much less of the essential work is done in monitoring services to ensure quality (only 37 percent done) and in reviewing the adequacy of the services to changing needs of persons and families (only 33 percent done).
• Over a one-year period, one in four clients is never contacted and one in five is contacted only indirectly.

Extra Staff Needed to Meet Essential and Best Practice Standards: In 1997, the following number of extra case/resource FTEs would have been necessary to fill the gap in work not being done above and beyond the 170 employed:

• 198 extra to meet minimum/essential standards, resulting in caseloads of 1:65;
• a further 163 to also meet optimal/best practice standards, resulting in caseloads of 1:46.

Projections of Staffing Needs: The work gap is increasing through time due to caseload growth projected to increase from 24,000 in 1997 to 33,550 by the end of the next biennium, the year 2001.

• By that time, 254 extra case/resource managers and 69.5 additional supervisors and administrative staff would be necessary to meet minimum/essential standards. These should be interpreted as minimum requirements, since a lack of proportional expansion of funding for services would create even more case management work as unmet needs increase, and the health and safety of clients are likely to be endangered.

Modified: Wednesday November 02 2005

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