## Abstract

Case management (CM) is one of the most commonly used services by individuals with intellectual and developmental disabilities (IDD), but little is known about the workers who provide CM. This study used a mixed methods approach to gain understanding of the CM workforce in one U.S. state. An online survey was completed by 35 IDD service directors (87.5% of directors in the state); and 113 CMs and CM supervisors participated in semistructured interviews and focus groups. Results indicated an annual crude separation rate of 28.2%, and participants often complained that turnover resulted in caseload sizes that prevented optimal outcomes for people with IDD. A limited applicant pool, duties focused on regulatory compliance, and inadequate wages were cited as major challenges for CMs.

## Background

A strong body of evidence has been published to document the crisis facing some segments of the workforce that support people with intellectual and developmental disabilities (IDD), particularly direct support professionals (DSPs; Bogenschutz, Hewitt, Nord, & Hepperlen, 2014; President's Committee for People With Intellectual Disabilities [PCPID], 2017) . However, little is known about other segments of the workforce that support people with IDD, including case managers. Case management (CM) is a service that is fundamental to the American system of supports for people with IDD. Though CM has been a Medicaid-reimbursable service option since the 1980s (Rosenbaum, 2008), there is very little empirical knowledge about the CM workforce, despite heavy utilization of CM by people with IDD.

### IDD Case Management

#### Definitions and variations

CM and support coordination (SC) is the “fundamental lynch pin” in the system of supports for people with IDD (National Association of State Directors of Developmental Disabilities Services [NASDDDS], 2018). Although definitions are often not precise or consistent from one setting to another, CM is often thought of as the process of assisting an individual secure and monitor the services they need, whereas SC tends to be more broadly defined as a process of building a comprehensive system of supports that suit the needs of a person with IDD and their family (as applicable). In the current study, the authors use the term CM to encompass both practices. Broadly, CM has two key features: (a) providing a point of connection between an individual with IDD and the publicly funded service system and (b) monitoring services to assure that they are of adequate quality and leading to attainment of important life outcomes (Cooper, 2006a). Though exact definitions of the roles and responsibilities subsumed under the CM service differ slightly based on state statutes, the Centers for Medicare and Medicaid Services (CMS, 2008) identified four allowable categories of activity that qualify as targeted CM, the mechanism most often used by states to provide CM to people with IDD (Cooper, 2006b): (a) assessment, (b) development of a care plan, (c) referral to services, and (d) monitoring of services, all of which are meant to be done in a collaborative fashion between the case manager and the person receiving services and/or their representative.

Though CMS defined targeted case management activities in the four categories listed previously, states may apply their own definitions of CM within federal guidelines. As such, CM is implemented differently from state to state (Amado, 2008; Amado et al., 2007). For example, in some states, CM is implemented at the state level, whereas in others, counties may be responsible for implementation of a system that is ultimately governed by the state. In some instances CM is delivered through public entities, whereas private nonprofits or managed care organizations may be responsible for provision of CM in other locales. Similarly, funding mechanisms for CM also vary among the states, with most states using some combination of federal, state, and sometimes local funds (Cooper, 2006b). Though Amado (2008) identified innovative models for CM for people with IDD, little movement has occurred to standardize CM practices nationwide.

CM competency sets have emerged since the 1990s (Treadwell et al., 2015). Though these are not specific to serving people with IDD, they provide some insight into the scope of CM practice more broadly. The Case Management Society of America (CMSA, 2010) developed and revised a set of 13 core skill standards for case managers across service sectors and populations, which represent an ideal standard for competent execution of CM duties (Treadwell et al., 2015). The CMSA standards are grounded in the principle of client-centeredness and cover a chronology of CM functions from client selection to termination, as well as the qualifications of case managers, legal considerations, and cultural competence (CMSA, 2010).

#### Utilization of CM

Although they do not provide a comprehensive picture of CM usage, the best available data on CM utilization in recent years has come from studies of Home and Community Based Services (HCBS) waivers. Based on these studies, the use of CM services is extensive, not only for people with IDD, but for other populations as well. Across all populations, CM is the most frequently used service in HCBS waivers, with utilization by 44% of all HCBS service users (Peebles & Bohl, 2014). Although utilization of CM occurs among a large portion of the HCBS population, costs for CM are low, relative to other service categories. Peebles and Bohl (2014) found that CM accounted for only 4% of HCBS expenditures, despite ubiquitous use, making it a relatively inexpensive service.

Specific to people with IDD, Rizzolo, Friedman, Lulinski-Norris, and Braddock (2013) found proposed expenditures of $454 million on HCBS CM services in the 2010 fiscal year, accounting for 1.929% of all projected HCBS expenditures for people with IDD. There are also suggestions that utilization of CM may be increasing among people with IDD who use HCBS. In an analysis of HCBS 1915(c) waivers, Friedman (2017) found an 8.4% increase in spending on CM from 2011 to 2015, during which time total spending on HCBS waivers dropped by 1%. ### IDD Workforce Crisis A crisis in the workforce that supports people with IDD has been documented since the early 1980s (Lakin & Bruininks, 1981; Lakin et al., 1983). This crisis has been most thoroughly observed related to DSPs, the individuals who provide direct personal support to people with IDD to assist with community participation, independent living, personal care, and daily living activities. The direct support workforce crisis has been characterized by a number of factors, including low wages considering the demands of the job, inadequate training, and high turnover rates (PCPID, 2017). Although different from CM in many ways, including level of education needed and core job functions, in the absence of empirical evidence about the CM workforce, the direct support workforce may provide some initial information about the workforce that provides community supports to individuals with IDD more generally. Recruitment and training of DSPs is difficult for a number of reasons (PCPID, 2017). The expansion of community services and supports for people with IDD has necessitated an increased demand for workers, at a time when the pool of potential workers has become smaller due to the aging of the population and competition from other industries to attract qualified workers (PCPID, 2017). Low wages, currently$10.72 per hour on average (Hiersteiner, 2016), exacerbate difficulties in recruitment, because many potential DSPs may need to utilize public benefits despite full-time work (Bogenschutz et al., 2014).

Turnover has also been documented as a challenge facing the direct support workforce for many years (Bogenschutz, Nord, & Hewitt, 2015; Braddock & Mitchell, 1992; PCPID, 2017). Annual turnover rates for DSPs nationwide were most recently estimated at 44.8% (Hiersteiner, 2016), compared with a national average of 3.7% annual turnover in all sectors of the American workforce (Bureau of Labor Statistics, 2018). The costs of turnover are high, estimated to over $79 million per year in New York state alone (Hewitt, Taylor, Kramme, Pettingel, & Sedlezky, 2015), and well over$2.3 billion per year nationally (PCPID, 2017). As with CM, competency sets have been established to define essential skills needed for DSPs, and there is evidence to suggest that improved competency-based training can help to reduce turnover at the worksite level (Bogenschutz et al., 2015). Stressful work conditions have also been noted as a major driver of turnover for DSPs (PCPID, 2017).

### Purpose of Study

Although the direct support workforce crisis has been well-documented, there is sparse knowledge about the CM workforce. There is growing use of CM services among people with IDD (Friedman, 2017), yet we know very little about the workers who provide this service that is so essential to the provision of community supports to individuals with IDD. This article aims to address this important gap in knowledge by addressing two main research questions:

1. What are the characteristics of the CM workforce in one state, including wages and annual turnover?

2. How are case managers for people with IDD experiencing their own work, as related to wages, training, and retention?

## Method

This study used multiple methods of data collection and analysis to develop a cross-sectional picture of the support coordination/case management workforce in Virginia. Interviews with CMs and CM supervisors, focus groups with SC/CMs and supervisors, and an online survey of local IDD service directors all informed this study. All methods used to conduct this study were reviewed and approved by the Institutional Review Board at the authors' affiliated university.

### State IDD CM Structure

Because states vary substantially in how they structure and deliver CM services to people with IDD, a note on the structure of CM service delivery in the state where this study was conducted is warranted. Virginia has a local system of CM, with the state being divided into 40 different publicly funded service delivery organizations that serve as single points of entry into the state's behavioral health and developmental services. Geographically, a particular organization will have a catchment area encompassing a county, city, or multiple geographically continuous localities. Each organization is financed through a combination of state and local funds, resulting in some discrepancies in fiscal resource availability between different areas of the state. Most CM services are delivered through the publicly funded local organizations directly, although some localities have contracted with organizations in the private sector to provide a portion of their CM.

### Data Collection

This study was conducted over a 6-month period in late 2017 and early 2018 as part of a larger initiative to strengthen CM in Virginia. Data were collected between November 2017 and January 2018.

#### Interviews/Focus groups

A semistructured interview protocol was used to guide interviews and focus groups with CMs and CM supervisors. Semistructured interviews allow the researcher to have a degree of stability in the lines of inquiry they pursue, while also having the flexibility to pursue more depth on issues that may emerge during a discussion with research participants (Doody & Noonan, 2013; Rowley, 2012). For this study, semistructured interviewing was an appropriate data gathering technique because the researchers wanted to gain a common understanding on some issues of primary importance to all participants, while leaving space to gain information on issues that were identified by individual informants.

The same protocol was used for individual interviews and for focus groups. The interview protocol was developed by the researchers in conjunction with personnel from the state's agency that oversees IDD services. The protocol was designed to elicit information on a range of topics including general work responsibilities of SC/CM, where redundancies existed in their workflow, and their ideas about what causes SC/CM turnover and ways to address it. The final protocol had 16 questions in total, some of which focused on the specific CM job functions, and others which focused on training, turnover, and suggestions for improvement of CM as a profession. As related specifically to gaining an understanding of the CM workforce, questions included, “What kind of orientation/training did you get to prepare you to be a CM?”, “What factors do you think make CMs think about leaving their job, and what factors make them stay?”, “What do you think are some concrete steps that can be taken to decrease turnover?”, and “What are your top three suggestions for improving CM services for people with IDD?” The wording of questions was tailored to whether a participant was a SC/CM or a supervisor. Participants were also asked to complete a brief, voluntary demographic questionnaire prior to beginning the main interview.

Interviews were administered in person and individually between one member of the research team and one respondent at offices of publicly funded CM service organizations throughout the state. After reviewing the aims and procedures for the study and securing verbal informed consent, the researcher proceeded to ask the 16 core interview questions in order, with additional discussion and questions on issues of importance that arose in each interview. Interviews typically lasted slightly under an hour. Focus groups followed the same general procedure, though they typically lasted slightly over an hour in order to provide time for all participants to express their views. Focus groups were held in meeting rooms at public libraries. All interviews and focus groups were digitally audio recorded with the permission of participants, with the exception of two individual interview participants who declined recording.

#### Online survey

An online survey was developed to elicit information from IDD service directors in each of the state's CM organizations. The IDD service directors are the individuals responsible for the overall administration of IDD services delivered from the publicly funded organizations. The survey was developed and delivered in REDCap, an online platform for survey management. The survey contained a series of questions about pay rates, caseload size, and data that could be used to calculate turnover, as well as a series of open-ended questions about recruitment and retention challenges, challenges in CM workflow, suggestions for reducing CM turnover, and suggestions for improving CM practices. In total, there were 13 questions in the online survey: seven quantitative responses and six qualitative items.

The researchers used an e-mail list from the IDD service director in each publicly funded CM organization to distribute the survey. A brief description of the survey was available in the introductory e-mail, along with a web link that the participant could use to access and complete the survey in REDCap. The quantitative questions about workforce indicators (pay, turnover, caseload size) were presented first, followed by the open-ended questions. In order to enhance response rate, a reminder e-mail was sent to all potential participants one week following the original solicitation for participation (Dillman, Smyth, & Christian, 2014).

### Participants

#### Sampling procedure

Participants for individual interviews were recruited from 21 of the state's 40 publicly funded CM provider organizations. The 21 targeted organizations were chosen by workers at the state's agency responsible for administration of IDD services to represent the demographics of the state and to ensure statewide representation in the study. Once the list of target organizations was obtained by the researchers, a member of the research team contacted the IDD service director for each of the identified organizations to ask for their cooperation in the study. All 21 organizations elected to participate, and directors were asked to send the researchers the names and e-mail addresses for three individuals within their organization: (a) the CM with hire date closest to September 1, 2015; (b) the CM with hire date closest to September 1, 2013; and (c) the CM Supervisor with hire date closest to September 1, 2013. The hire dates for CMs who were invited to participate in interviews were selected in order to gain the perspectives of individuals who were newly entering their work with each agency as well as those who had experienced the significant changes in the state's IDD service system that had taken place since 2012. The researchers contacted those individuals by e-mail to solicit participation, and all individuals who were contacted agreed to participate in the interview. Interviews were then scheduled and the interview protocol was sent to participants in advance of their participation.

Five focus groups were held with CMs and CM supervisors: one in each of the state's five planning regions. A flyer announcing the date, time, and location of each focus group was distributed to IDD service directors in each organization with a request to distribute the flyer to their CMs and supervisors via e-mail.

The online survey was sent to the entire population of the state's IDD service directors: 40 individuals total. The survey was distributed by the researchers via e-mail, using an e-mail list of IDD directors that the researchers obtained from the state agency in charge of IDD services.

#### Sample characteristics

There were a total of 113 participants in the qualitative portions of this study, including 61 who participated in individual interviews and 52 who participated in focus groups. Of the 113 participants, 82 were CMs and 31 were CM supervisors. A demographic profile of the participants in the individual interviews and focus groups may be viewed in Table 1. In line with the CM workforce generally, the participants were largely female (n = 101, 89.4%), racially diverse, and the majority had a college degree or above, as required by regulations for CM in the state.

Table 1

Sample Characteristics: Interviews and Focus Groups (n = 113)

The online survey was distributed to the entire population of IDD services directors (40 individuals in total) in each of the publicly funded CM service organizations in the state, and was completed by 35 of them, for a response rate of 87.5%. Because of the small sample size, demographic characteristics of the respondents were not collected.

### Data Analysis

Before analysis began, digital audio recordings of interviews and focus groups were transcribed verbatim by a professional transcription service. The transcripts became our texts for analysis. Qualitative analyses followed the method of thematic analysis proposed by Braun and Clarke (2006). The researchers elected to use thematic analysis in this study because it provides clear guidelines on how to approach data in an inductive manner, while allowing the researcher flexibility in how to pursue themes that emerge from the data (Braun & Clarke, 2006; Miles, Huberman, & Saldaña, 2014).

Analyses were conducted in Dedoose 8, a cloud-based application for qualitative data analysis. There was one primary analyst who was responsible for coding, with other authors providing peer-review and consultation at key times in the data analysis process. Following Braun and Clarke's (2006) procedure for thematic analysis, all members of the research team began by familiarizing themselves with the data by carefully reading the transcripts. The primary coder then conducted a first round of analysis, during which initial codes were applied to the data. The entire research team then reviewed the initial codes and searched for themes. The primary reviewer then reviewed those themes against the data in a second round of coding and themes were refined. Finally, the research team reconvened to devise a scheme for organizing the themes for reporting and dissemination.

Quantitative analyses were conducted in SPSS 24. General workforce indicators were calculated descriptively in order to gain a sense of typical SC/CM wages, caseload size, and annual crude separation rates.

## Findings

Our findings are organized around three main areas of concern in the study of the human service workforce, as informed by literature about the direct support workforce and expressed by study participants: (a) recruitment and training, (b) compensation, and (c) retention and turnover. Within each area are the primary themes from our analysis that related to that concern.

### Recruitment and Training

Recruiting qualified CMs and training them to competently meet the demands of the job was a challenge identified by many supervisors and IDD directors.

#### Limited applicant pool

Most supervisors noted that one of their greatest workforce challenges was the limited pool of applicants for open CM positions. Although CMs were hired locally, the state set minimum qualifications for hiring CMs, including a 4-year university degree in a human service field, at least 1 year of experience working with people with IDD, and at least 1 year of experience writing individualized service plans. Difficulties in identifying job applicants who met minimum requirements were almost universally reported by IDD Directors and supervisors. One individual, sharing the perspective of many others, remarked, “I've had many applicants that I felt were qualified through experience and working with individuals with IDD, but did not have the degree or had the degree and experience, but did not have experience writing plans.”

Struggles identifying qualified applicants were particularly pronounced in rural areas of the state, where IDD Directors and supervisors often pointed out that new workers with college degrees often preferred to live in areas with more amenities, making their pool of potential workers particularly limited. One IDD Director from a rural part of the state shared their thoughts when asked about the challenges facing her recruitment efforts:

Finding qualified applicants with a degree that are willing to work in our area. We are rural and do not have the amenities that are offered in a urban environment, including multiple options for personal health care, dentistry, schooling, and housing that would attract someone to the job and location.

Additionally, several IDD Directors noted that the entry-level pay they could offer to new CMs was a deterrent to potential job applicants. Many complained of limited reimbursement for CM services and competition from other employers in the human service field, especially in the private sector, who advertised higher starting pay. Others worried that the disconnect between mediocre pay and the high demands of the job may have led some potential applicants to look for employment elsewhere, as summarized by one IDD Director who said:

Applicants do not feel that the level of work required matches the salary. We used to have multiple applicants “stepping up” to the CM role from [other disability-related services], but this does not happen anymore. We hear that the work level is not worth the minor increase in pay.

#### Onboarding practices and continuing education

Most CMs reported limited training when they began their jobs. Although the reported onboarding practices were variable from one location to another, most included basic training around agency policies and procedures, a mandatory set of online modules about the state's CM system, and some degree of shadowing of more experienced CMs. Shadowing senior CMs was reportedly the most useful practice for most new CMs, especially when it included many aspects of the job. However, many CMs reported that shadowing opportunities were limited or that they were not offered for a long enough period of time to truly help them learn the job. Although some CMs reported shadowing that lasted for a month or longer before they got their own caseload, others reportedly were expected to take responsibility for a caseload of their own within 2 weeks of hire, a timeframe they felt did not afford them enough experience to competently conduct their work. Reflecting this line of thinking, one CM explained her experience and perspective of the onboarding process:

Basically when we come here we're told, ‘Hey, go with certain people.' That doesn't always arise. I feel like we should rotate for a month with each case manager that's here that has experience because everyone in the building does stuff differently.

One particularly important area for training that was identified by many participants was person-centered planning. The state required an overview of person-centered planning practices for new CMs, but ongoing training in person-centeredness was not a requirement, though many CMs noted that it might be helpful on an ongoing basis. Even though person-centered planning training was required of new hires, some individuals did not receive it, largely due to the need to get CMs into the field as soon as possible after hire to help relieve large caseloads. One supervisor noted, “I've had case managers here since maybe September, and there hasn't been a [person-centered planning] training available for them to go to yet. So that's not enough training where you can actually go in and talk to a person.”

Many CMs noted that online training was the way in which they typically pursued ongoing training for professional development, often because in-person trainings were not readily available. Topically, many individuals wanted more training to meet the needs of people with IDD with specialized needs, such as autism spectrum disorder or co-occurring mental health issues. Most people experienced a preference for in-person training, such as one case manager in a focus group who noted, “We're not getting the [in-person] training. And a few years ago, we used to have those meetings and doing the training we fed off each other and you got to hear that I'm not the only one out there.”

### Compensation

As reported by the IDD Directors who completed an online survey, the mean wage for CMs in the state was $44,149, with a very wide variation between organizations (the lowest CBS mean wage reported was$29,000 and the highest was $68,000). These findings are likely more accurate than the figures reported for individual interview and focus group participants as reported in Table 1 because they include reports from 35 of the state's 40 publicly funded CM organizations. Entry level wages were somewhat lower. The mean starting salary for CMs, as reported by IDD Directors, was$40,140 (median $43,428), again with a wide range of reported wages, from$26,000 to $60,000. For both entry-level salaries and overall mean salaries, the wide range typically reflected major cost-of-living differences in various parts of the state, although there were notable differences even within the same regions. Among CMs and supervisors who took part in interviews and focus groups, there was a widespread sentiment that the pay they received was inadequate for the skill required to perform the job. This thinking was nearly unanimous, even in organizations with the highest salaries (which were generally located in parts of the state with very high living costs). The perception of being unfairly compensated for the work performed by CMs left many feeling demoralized. One CM from a poor region of the state shared the sentiments echoed by many of her colleagues when she said, “If you know that you are being compensated for the actual work that you put in you feel better. But we're like, I'm burned out, I'm tired, and then my check looks like [laughter] nothing. What's the point?” The feelings of CMs were echoed by IDD Directors, who often focused on the difficulties of recruiting and retaining CMs with salaries that were inadequate. As noted by one Director, “Pay does not compete with retail employers such as Hobby Lobby.” #### Fringe benefits In contrast to salaries, the availability of fringe benefits for CMs was a major driver of retention. The benefits offered through the CM organizations were typically city or county government benefits, which provided stability and reasonable price for health insurance as well as paid leave time, which were highly valued by CMs. The availability of reasonably priced health insurance was of particular importance for many interview participants, who commented that they did not leave for private sector jobs because their insurance would be more expensive or because they feared a lapse in coverage during a job transition. Paid time off was also valued by CMs who were interviewed, although many reported that it was stressful to take time off because many of their work demands were on a tight monthly schedule, so taking time away to attend to personal matters or go on vacation sometimes became a stressful prospect. ### Retention and Turnover #### CM turnover Based on data reported by IDD Directors, annual crude separation was calculated for each of the 35 publicly funded CM service organizations that reported data. Annual crude separation, a commonly used method of calculating turnover rates, was calculated as: Based on those calculations, the mean annual crude separation rate across all reporting local publicly funded CM service organizations statewide was 28.2% (median 26.7%). As with CM salaries, there was a wide range of turnover rates reported by individual organizations, ranging from 0% to 75% in the previous year. #### Job stress and burnout A major driver of job stress and burnout reported by virtually all participants in this study was high caseload size, in relation to the paperwork and service monitoring demands of the job. High caseload sizes were reported across the state by local IDD service directors. The mean caseload size reported by IDD services directors was 30.9 individuals with IDD per CM. Comparatively, IDD service directors also reported on what they felt the optimal caseload size would be, in order to achieve good service outcomes while fairly distributing workload to CMs. The optimal caseload size reported in the statewide survey was 24.3, suggesting that caseloads should ideally be reduced by 21%. Based on interviews and focus group data, job stress was a leading cause of turnover among CMs. Interview participants often shared their stories of how job-related stress affected their lives, even outside of work. This stress often took a physical and emotional toll on individuals, including reports of elevated blood pressure, difficulty sleeping, and fatigue. In some of the most pointed expressions of the effects of job stress, some CMs reported the emergence of mental health concerns, which were exemplified by one CM who said, “I've known a few case managers who have had to get put on anxiety and depression medications when they became employees here and a few of them that have left because of that, myself included.” Many CM noted that they were likely to exit the profession when an opportunity to do so became available. They often noted that the high stress of their work, coupled with the low pay many participants reported, made continuing work as an IDD CM unattractive compared with other lines of work they could pursue. As stated by a CM from a rural area, recounting her contemplation of changing careers: I was tired of the month to month, that whole month just running, running, running, and then at the end of the month, trying to catch up on all this paperwork, all this documentation. And it's never enough. It's never right. There's always something's wrong. ‘Correct this. Correct that.' And the pay, it was just like. Why do all this for this amount of money when there are other people out here…making way more money than me and not as stressed. Although there were a few CMs who saw a long-term career in IDD CM, most did not see a future for themselves in the role. Among younger CMs, many hoped that serving for a couple years as a IDD CM might open up doors for them to move into a CM position with another population, such as with older adults or people with mental illness, because those positions were seen as using the same skill sets in less stressful work conditions. For those CM who did see a long-term career supporting people with IDD, direct CM was often not their career objective. Rather, many saw the potential for advancement and were positioning themselves for promotional opportunities that would take them away from the provision of CM directly to people with IDD and into a management role. One CM from one of the largest publicly funded CM service organizations in the state described her strategy: I changed [jobs] because [case manager] is a lot of work but also because I want to move up to a supervisor position. I've already applied and interviewed twice for a supervisory position. I didn't get it either time so I felt like I needed to broaden by skills and my knowledge. Hopefully this would be something that would help me move up. #### Strategies for retention Participants had a multitude of suggestions about how to improve the job of CMs, as well as how to improve retention. Though many participants focused on improving compensation as an important way to retain CMs, many individuals had insights that went beyond simply increasing pay. The development of CM career ladders, reduction of paperwork duties, and giving CM a valued voice within the field were three such strategies offered by several CMs. One of the most common retention strategies that CMs and CM supervisors noted was the development of CM career ladders. Although specific suggestions for how a career ladder should look varied based on characteristics of individual CM organizations, many individuals noted that they would like more opportunity to specialize in supporting subpopulations of individuals with IDD (such as people with autism spectrum disorder or individuals with co-occurring mental illness) or to help train new CMs who are coming into the profession. Regardless of the specific nature of the career ladder proposed by many participants, it was quite common for CMs and supervisors to talk about how important it was to see the potential for advancement, and that pay should be commensurate with level of skill and experience, as one participant from a metropolitan part of the state shared, [I]t's just kind of difficult. It's not a lot of room for growth. I feel like there should be maybe a team leader maybe for that can help maybe. And then another thing, too, which is kind of frustrating, a person could be here for years and then someone new coming in, they're going to start at the same salary as you. In addition, many CMs, especially those with substantial experience supporting people with IDD, saw that their tasks had shifted away from the direct interactions with people with IDD that initially drew them to the profession to more administrative and compliance-oriented activities that many individuals referred to as paperwork. There was a desire among many CMs to have more time to get to know the people with IDD whom they supported, so they could better monitor their progress and link them to services that could improve their quality of life. For most CMs, however, the time spent interacting with the individuals they supported was overshadowed by administrative tasks, as summarized by a CM supervisor: I think it's to the point where [CMs] don't feel like they're actually taking care of somebody's needs, that they're only doing the paperwork for paperwork's sake, or checking off requirements, and they don't feel that they're actually making a difference in somebody's life. CMs also wanted to have a valued voice in their workplaces and within the state's decision-making processes. Many felt that they were subject to arbitrary decisions that affected how they conducted their work, and that changes, both minor and major, were made with little communication or input from CMs working on the ground. This perceived exclusion from decision-making processes was frustrating for many CMs, who felt that having a voice in important decisions would help to create systems that would be workable to CMs, thus reducing stress and improving retention. ## Discussion This study's results indicate that CMs may represent another frontier in the well-documented crisis facing the workforce that supports people with IDD. Much like the crisis in the DSP workforce, high turnover, inadequate training, and limited career prospects in the CM workforce may contribute to less than optimal outcomes for people with IDD, because linkages to appropriate supports and adequate monitoring of those supports cannot be expected when the CM workforce in unstable or ill-prepared. ### CM Workforce Status Findings of this study suggest an emerging crisis in the CM workforce supporting people with IDD, characterized by low wages and high turnover. At the low end of the wage spectrum reported in this study, an annual salary of$29,000 would translate to just about $13.94 per hour, based on a 40-hour work week. The mean CM salary reported statewide would equal$21.22 per hour for a job requiring at least a bachelor's degree, previous experience working with people with IDD, and a highly specific level of training in order to perform job tasks. These wages, especially at low end of the spectrum, are only marginally above the Federal Poverty Guideline for 2018 (United States Federal Register, 2018), but well within 150% of the Federal Poverty Guideline, which would mean that many case managers with children may qualify for public benefits such as Medicaid (under Medicaid Expansion) or State Children's Health Insurance Programs, despite engaging in full-time professional level work. The reported salaries are also well beneath the state's median household income of \$68,114 (United States Census Bureau, 2017).

With a statewide annual crude separation rate of 28.2%, turnover among CM is at crisis levels. Although CM turnover is not as acute as it is for DSPs who support people with IDD (Hiersteiner, 2016), in comparison to the 3.7% annual turnover rate for American workers as a whole (Bureau of Labor Statistics, 2018), the rates observed for CMs in this study are quite high. This high level of turnover likely has a detrimental effect not only on the organizations that employ CMs, but also on the people with IDD who rely on CMs to monitor the quality and effectiveness of services and to link them with service providers who are able to meet their support needs. In the worst instances, this turnover and instability of oversight may mean that individuals with IDD must live in unsafe conditions if CMs are not able to provide adequate monitoring due to high turnover and reportedly larger than optimal large caseload sizes.

In addition to high turnover and low wages, difficulties in recruitment and training of CM also bear resemblance to the workforce crisis facing DSPs who support people with IDD. Many CM supervisors and IDD Directors from throughout the state commented on the increasing difficulty they are having finding qualified job candidates to fill open CM positions, leaving them to consider almost any applicant who met basic qualifications in many instances. The same phenomenon has been observed in the direct support workforce, where increased demand for workers, driven by the expansion of community-based services and supports and a reduction of the size of the traditional labor force (due largely to the aging of the population) has created difficulty in recruiting DSPs (PCPID, 2017; Scan Foundation, 2012; Ward, Smith, Bales, & Sandberg, 2009). When CMs are hired, training opportunities are limited and often inconsistently offered, based on the narratives offered by this study's participants. As with DSPs, training may pay dividends in the retention of more qualified workers (Bogenschutz et al., 2015) as well as in potentially improved outcomes for people with IDD.

On the whole, there is much similarity between this study's findings related to the CM workforce and previous literature about the direct support workforce crisis, adding urgency to the need to address the challenges facing the workers who are responsible for providing direct, front-line support to individuals with IDD. Addressing all levels of the workforce crisis is a vital step in ensuring the stability and continued development of community services and supports for people with IDD who rely on competent and consistent workers to support their community inclusion, health, and safety.

### Implications for Policy and Practice

This study suggests a need for intervention at multiple levels in order to improve the CM workforce. First, at the policy level, the low wages and higher than optimal caseload sizes reported by participants suggest a need to adjust reimbursement rates for CM service at the state level. Without such an adjustment, it is likely that wages will continue to be low. Caseload sizes also warrants closer examination. Although the typical caseload sizes reported in this study are somewhat lower than national averages (Amado et al., 2007, Cooper, 2006a), there is significant state-to-state variation in the roles that CMs play in coordinating and monitoring services and in the regulatory paperwork they are required to complete. A more comprehensive examination of the overall workload of CMs would be useful in helping states align caseload size with the typical time demands that CMs experience to adequately meet the needs of each person on their caseload.

Second, it may be worthwhile to consider ways for CMs to receive cost-effective training to help them gain the competency needed to confidently execute their job duties. Considering the wide array of skills indicated for CMs in a national conceptualization of practice standards for CMs across service sectors and populations (CMSA, 2010), it is apparent that comprehensive competency-based training is needed for CMs, both at onboarding and on an ongoing basis. A recent study of DSPs supporting individuals with IDD (Bogenschutz et al., 2015) suggested that turnover may be reduced when improved training is applied, and given the many similarities between the direct support workforce and the CM workforce, the same may hold true for CM as well.

Additionally, it may be useful, at the organizational level, to explore ways to recognize the efforts of CMs and to build career ladders that will help them see a long-term career in the profession. A career ladder will vary in different organizations, but building it in ways for CMs to take on additional responsibility, commensurate with training and experience, and providing opportunities to specialize in providing CM to specific populations (such as individuals with co-occurring mental health concerns or individuals with high medical needs) would provide avenues for advancement while allowing CMs to pursue work with specific populations of interest.

### Future Research Agenda

Because very little is known about the CM workforce that supports people with IDD there is ample space for further investigation. Additionally, because CM is the most frequently used type of service in HCBS (Rizzolo et al., 2013) with utilization appearing to be on the rise (Friedman, 2017), understanding the status and needs of the individuals who provide this foundational service to people with IDD is of high importance.

The structure of CM varies widely from state to state (Amado, 2008; Cooper, 2006a), so an important first step in future research may be to gain a better understanding of the status of the CM workforce in different states' CM service models. This would enable a better understanding of the status of the CM workforce nationally, while gathering more nuanced information about the relative strengths and weaknesses of various approaches to CM across the country and how different CM models relate to job performance, satisfaction, and turnover.

Testing interventions that may stabilize and improve the competency of the CM workforce would also be a potentially fruitful frontier in future research. For instance, designing, delivering, and evaluating the effects of systematic training to improve the competency of CMs would be particularly beneficial. Evaluating the effects of such training on organizational turnover rates, and the perceived effectiveness of CMs in conducting their duties would be especially useful, as would examining the effect of CM training on the outcomes of individuals with IDD, because better monitoring and linking practices could potentially translate to improved outcomes in health, safety, and community participation.

### Limitations and Conclusion

This study has some notable limitations. First, it was conducted in only one state, and because CM services vary in structure across the county (Amado, 2008), it is important to note that the findings from this study may not apply to other states where CM practice may be considerably different. Although this study had a large and diverse sample that was representative of CMs in the state where it was conducted, caution should be exercised in drawing similar conclusions in other jurisdictions.

Second, this study was conducted at a time of significant change in the state's IDD service system as a whole, and many of these changes had a direct effect on CMs. Conducting this study at this particular moment in time may have resulted in intensified feelings of frustration and stress among some CMs, and may have played a role in increasing turnover rates as a whole. Although many experienced CMs who participated in interviews noted that their jobs had been stressful for some time, it is impossible for us to know if or how statewide service system changes affected CMs.

Despite these limitations to the research, this study provided one of the only recent examinations of the CM workforce, and drew important parallels to the workforce crisis that has been documented in other parts of the IDD service system nationwide. Based on these findings, it is apparent that substantial efforts must be undertaken to stabilize and strengthen the workforce that provides the ubiquitously utilized service that links people with service providers who can best meet their needs and monitors the effectiveness of those services on a continual basis. CM is a vital service for many people with IDD, and that service may only be effective if the workers who provide it are adequately trained, stable, and fairly compensated.

## References

References
,
A.
(
2008
).
Innovative models and best practices in case management and support coordination. Research Policy Brief, 19(1)
.
Minneapolis, MN
:
Research and Training Center on Community Living, Institute on Community Integration, University of Minnesota
.
,
A.
,
Smith
,
G.
,
Larson
,
S.
,
Roehl
,
A.
,
Fortune
,
J.
,
Fields
,
J.
, …
McBride
,
M.
(
2007
).
Redesigning case management services for people with disabilities in Minnesota: A report to the Legislature
.
Minneapolis, MN
:
Institute on Community Integration, University of Minnesota
.
Bogenschutz
,
M.
,
Hewitt
,
A.
,
Nord
,
D.
, &
Hepperlin
,
R.
(
2014
).
Direct support workforce supporting individuals with IDD: Current wages, benefits, and stability
.
Intellectual and Developmental Disabilities
,
52
,
317
329
.
Bogenschutz
,
M.
,
Nord
,
D.
, &
Hewitt
,
A.
(
2015
).
Competency-based training and worker turnover in community supports for people with IDD: Results from a group randomized controlled study
.
Intellectual and Developmental Disabilities
,
53
,
182
195
.
,
D.
, &
Mitchell
,
D.
(
1992
).
Residential services and developmental disabilities in the United States: A national survey of staff compensation, turnover, and related issues
.
Washington, DC
:
American Association on Mental Retardation
.
Braun
,
V.
, &
Clarke
,
V.
(
2006
).
Using thematic analysis in psychology
.
Qualitative Research in Psychology
,
3
,
77
101
.
Bureau of Labor Statistics
.
(2018
,
January)
.
Job openings and labor turnover
. .
Case Management Society of America
. (
2010
).
Standards of practice for case management
.
Centers for Medicare and Medicaid Services
. (
2008
).
The Supplemental Appropriations Act, 2008 & Implementation of CMS 2237 IFC: Targeted case management
.
Cooper
,
R.
(
2006a
).
Medicaid and case management for people with developmental disabilities: Options, practices, and issues
.
Alexandria, VA
:
National Association of State Directors of Developmental Disabilities Services
.
Cooper
,
R.
(
2006b
).
Survey of state case management policies and practices
. .
Dillman
,
D.
,
Smyth
,
J.
, &
Christian
,
L.
(
2014
).
Internet, phone, mail, and mixed-mode surveys: The tailored design approach
.
Hoboken, NJ
:
John Wiley & Sons
.
Doody
,
O.
, &
Noonan
,
M.
(
2013
).
Preparing and conducting interviews to collect data
.
Nurse Researcher
,
20
,
28
32
.
Friedman
,
C.
(
2017
).
Community integration of people with intellectual and developmental disabilities: A national longitudinal analysis
.
Disability & Health Journal
,
10
,
616
620
.
Hewitt
,
A.
,
Taylor
,
M.
,
Kramme
,
J.
,
Pettingel
,
S.
, &
Sedlezky
,
L.
(
2015
).
Implementing direct support professional credentialing in New York: Technical report
.
Minneapolis, MN
:
University of Minnesota, Research and Training Center on Community Living
.
Hiersteiner
,
D.
(
2016
).
National core indicators: 2015 staff stability survey report
.
Cambridge, MA
:
Human Services Research Institute and the National Association of State Directors of Developmental Disabilities
.
Lakin
,
K. C.
, &
Bruininks
,
R.
(
1981
).
Occupational stability of direct-care staff of residential facilities for mentally retarded people
.
Minneapolis, MN
:
University of Minnesota, Center on Residential and Community Services
.
Lakin
,
K. C.
,
Hill
,
B.
,
Bruininks
,
R.
,
Hauber
,
F.
, &
Krantz
,
G.
(
1983
).
Factors related to job stability of direct-care staff of residential facilities for mentally retarded people
.
Journal of Community Psychology
,
11
,
228
235
.
Miles
,
M. B.
,
Huberman
,
A. M.
, &
Saldaña
,
J.
(
2014
).
Qualitative data analysis: A methods sourcebook (3rd ed.)
.
Thousand Oaks, CA
:
Sage
.
National Association of State Directors of Developmental Disabilities Services
. (
2018
).
Case management/support coordination
. .
Peebles
,
V.
, &
Bohl
,
A.
(
2014
).
The HCBS taxonomy: A new language for classifying Home and Community Based Services
.
Medicare & Medicaid Research Review
,
4
(
1
).
President's Committee for People with Intellectual Disabilities
. (
2017
).
America's direct support workforce crisis: Effects on people with intellectual disabilities, families, communities, and the U.S. economy
.
Washington, DC
:
Author
.
Rizzolo
,
M.
,
Friedman
,
C.
,
Lulinski-Norris
,
A.
, &
,
D.
(
2013
).
Home and Community Based Services (HCBS) waivers: A nationwide study of the states
.
Intellectual and Developmental Disabilities
,
51
,
1
21
.
Rosenbaum
,
S.
(
2008
).
The CMS Medicaid targeted case management rule: Implications for special needs service providers and programs
.
Hamilton, NJ
:
Center for Health Care Strategies
.
Rowley
,
J.
(
2012
).
Conducting research interviews
.
Management Research Review
,
35
(
3/4
),
260
271
.
Scan Foundation
. (
2012
).
Who provides long term care in the United States?
Long Beach, CA
:
Author
.
,
J.
,
Perez
,
R.
,
Stubbs
,
D.
,
McAllister
,
J.W.
,
Stern
,
S.
, &
Buzi
,
R.
(
2015
).
Case management and care coordination supporting children and families to optimal outcomes
.
New York, NY
:
Springer
.
United States Census Bureau
. (
2017
).
Quick facts: Virginia
.
United States Federal Register
. (
2018
).
Annual update of the HHS Poverty Guidelines
.
Ward
,
K.
,
Smith
,
C.
,
Bales
,
S.
, &
Sandberg
,
K.
(
2009
).
Survey of direct care workers in Alaska
.
Anchorage, AK
:
University of Alaska-Anchorage Center for Human Development
.

## Author notes

This research was funded by a grant from the Virginia Department of Behavioral Health and Developmental Services to the Partnership for People with Disabilities.