CAIRSS Remote Supports Integration White Paper
Best Practices for Remote Supports Integration into State HCBS Waivers
Ben Richter, Director of Development, Night Owl Support Systems, LLC - Member of CAIRSS
Abstract
The persistence of the national staffing crisis in long-term care services, particularly residential services for people with intellectual and developmental disabilities, necessitates the integration of alternative service models. Remote Supports, a service in which technology connects an individual to a caregiver at a remote location, is one such alternative. It has been implemented into HCBS waivers in many states, where it has demonstrated a capacity to reduce the negative impact of staffing crisis and generate savings for Medicaid. However, the implementations among different states have not been equal. States that preserve the financial incentive for providers to use Remote Supports, establish robust requirements for Remote Supports operation, and allow individuals to utilize as many units of the service as they desire to reach their intended outcomes set an example of how such implementations should be accomplished. We urge CMS to issue federal guidance to promote state establishment of Remote Supports services in their HCBS waivers and to promulgate the benefits of other states’ successful integration efforts to help them move toward integration that removes the most barriers toward utilization and provides the most benefit to the most people.
Background
The long-term care services industry has been enduring a protracted staffing crisis for several years. High turnover of Direct Support Professionals (DSPs) results in higher costs for organizations (National Core Indicators, 2022; Larson, et al., 2016). The consequences of this crisis have several downstream effects, including discontinuation of programs and services as well as leaving providers struggling to achieve quality standards (ANCOR, 2022). The persistent nature of the staffing crisis, despite federal relief from sources such as the American Rescue Plan Act, demonstrates that infusions of funds are not sufficient to solve it. There is a need to fundamentally reconsider the structure of residential services to integrate Remote Supports in ways that will help reduce aggregate reliance on in-person staff.
State HCBS administering departments and providers have come together in many states to develop and implement technology-based services and solutions to help reduce reliance on in-person staff and increase participants’ independence and community-integration. Ohio, Missouri, Minnesota, and Maryland are just a few of the states to have adopted a “Technology First” framework for addressing the needs of HCBS participants (Wagner, Tasse, Ornan, 2022).
Functionally, efforts such as “Technology First” initiatives seek to prioritize the implementation of supportive technology services and solutions available to HCBS participants to achieve the positive outcomes discussed earlier. Examples of these services and solutions include Remote Supports, assistive technology, environmental controls, and supportive applications.
The onset of COVID-19 and the flexibilities allowed through Appendix K created the exigencies which prompted many providers of residential HCBS services to explore technology-based solutions to their persistent staffing problem. With the rollback of these flexibilities, many states and providers are left deciding how to navigate their way out of the public health emergency without relinquishing many of the innovative service models they have developed (Tanis, 2021).
Fortunately, there are services that utilize technology to reduce reliance on staff and improve the outcomes of the people supported. One service, the focus of this paper, is Remote Supports. Remote Supports are uniquely positioned to create the broadest possible benefit for states, individuals, and providers, if the method by which they are integrated into HCBS waivers is correct. In the following text, we will examine Remote Supports, benefits of the service as a whole, the different permutations of definitions as they currently exist in HCBS waivers, and how those definitions support or hinder the potential benefits of the service for all stakeholders.
Remote Supports Defined
According to the Coalition for the Advancement and Integration of Remote Supports Services, the following is the definition for Remote Supports services:
“Remote Supports is a technology-based service that allows trained Remote Support Professionals (RSPs) to deliver live support to an individual at a remote location. Its primary goal is to foster an individual’s safety and to allow them to live more independently. Remote Supports are delivered by awake, alert Remote Support professionals whose primary duties are to provide Remote Supports from the provider’s secure Remote Supports facility. To ensure safety and HIPAA compliance, this facility should have appropriate, stable, and redundant connections. This should include, but is not limited to backup generators, multiple internet service connections, battery backups, etc. Remote Supports should always be selected as the result of decisions made by the individual and their team. Remote Supports must be incorporated into the individual’s personalized service plan and must be executed in a person-centered fashion.” (CAIRSS, 2021).
While CAIRSS and its constituent members consider this the primary definition of Remote Supports, many states have definitions within their HCBS waivers that vary to greater and lesser degrees. Indeed, many states functionally provide Remote Supports under other names, or combine Remote Supports provisions with residential service definitions (as a virtual service option) or with assistive technology.
Remote Supports Compared to Other Technology Solutions
Remote Supports differ from Assistive Technology, Environmental Modifications, Personal Emergency Response Systems (PERS), and other related HCBS services in fundamental ways. First, and perhaps most importantly, Remote Supports is a service (not to be confused with the HCBS Participant Services, under which all HCBS offerings are defined). Remote Supports occur over time and are not related to the distribution of discrete pieces of technology, but rather how specific technology systems allow for the person-to-person support of an RSP to an individual-served.
Assistive technology, as traditionally defined by the 1988 “Tech Acts” and subsequent reauthorizations in 1994, 1998, and 2004, refers to discrete devices that improve the functional capabilities of people with disabilities. There is a one-to-one correlation between the device provided and the outcome supported. Similarly, Environmental Modifications, Vehicle Modifications, and Accessibility Adaptations refer to discrete integrations of specific technologies intended to address a specific set of outcomes. Remote Supports are a service intended to address several outcomes, accomplished through technology, whereas Assistive Technology are devices that are purchased and intended to address specific outcomes.
Remote Supports are also related to PERS, insofar as they both function as a system that provides a service. They both establish a mechanism by which individuals can contact a staffed call center in case of emergency. However, they still differ in three substantial ways.
Firstly, the call center associated with PERS devices is almost always staffed with representatives who know nothing about the individual other than very basic demographic information such as name and address. They only retain the information needed to dispatch emergency services. Remote Supports, on the other hand, have similar remote locations from which communications are established, but are staffed by trained RSPs who are more akin to DSPs than EMS dispatchers. These RSPs are trained on a set of protocols, which act as a plan of care for Remote Supports services, that include more information than basic demographics. What’s more, their training includes many of the HCBS-specific subjects, including HIPAA, Preventing Abuse, Neglect, and Exploitation, Rights of Persons with Disabilities, etc., that DSPs are required to undertake.
Secondly, Remote Supports are not simply a standby service that is rarely engaged, like PERS. Instead, they are an active part of an individual’s daily life. Examples of discrete activities performed by RSPs include: providing prompts, redirecting individuals, giving reminders, and responding to non-emergency communications initiated by the individual.
Thirdly, Remote Supports function as a replacement for some hours of residential staffing services. It is commonplace in the industry that individuals often have staff in their homes during “downtime” or periods of inactivity where the individual’s needs are low, but not so low that the staff person can leave them alone in their home. An example of common downtime is during overnight periods. Remote Supports flourished through much of its twenty-year history by replacing overnight staffing hours. These periods have low-activity, and when help is needed, responders or backup staff can be dispatched to aid them.
Core Components of Remote Supports
Remote Supports are comprised of four core components: the individual served, the Remote Support Professional, the technology used to connect them, and the backup/response staff. Understanding these core components proves essential to grasping the effects of regulatory decisions on service delivery and the potential for benefits of the service (to be outlined in the following section) to be diminished through inadvertent regulatory action.
During the provision of Remote Supports, an individual served is at their home (or in the community, but for the purposes of this prototypical example, we will focus on the residential situation) and the RSP is working from a central station. Through technology, including sensors and two-way audio/video communication, the RSP is supporting the individual as they accomplish their Activities of Daily Living. Should the individual require in-person assistance, the fourth component, backup response, can be dispatched to the home in a timely manner. This arrangement proves efficient, as it at once allows the individual to have more time physically alone in their home while still preserving the capacity for rapid response if in-person help is required.
Each of these components is essential for the provision of safe and effective Remote Supports. Without the technology, the RSP and individual are unable to communicate, which presents safety concerns. This is why regulations regarding technical backups, including redundant connections and backup generators, are important. Without backup responders, Remote Supports would be unable to appropriately account for unforeseen circumstances that require in-person care, presenting safety concerns.
The necessity of these components, in addition to the responsibility for adequately regulating them, supports the creation of a separate definition for the service. Funding or otherwise authorizing the service through current service models such as AT and PERS does not provide the regulatory flexibility necessary to ensure the safe operation of Remote Supports.
As will be demonstrated later, the varying methods by which states implement Remote Supports, including, in many cases, by placing them within AT and PERS services, has impacts on the relative benefits of the service for the individuals using HCBS waiver services. Such marked differences support the creation of a Remote Supports definition at the federal level, one which all states can reference when updating or creating their Remote Supports service models and which will preserve the core components that have proven safe and effective.
Benefits of Remote Supports
With the understanding that benefits of Remote Supports are subject to the regulatory context in which they are offered, let us turn now to the benefits of Remote Supports when adequately provided for in HCBS waivers.
First and foremost is the benefit to the individuals who receive these services. For many people with intellectual and/or developmental disabilities who receive residential services through HCBS waivers, in-home staff are often present for times when active, hands-on support is not necessary. This “down time” can be a result of administrative determinations of the level of supervision (for example, if individuals are deemed as requiring twenty-four hours of care) or the result of simple pragmatism (for example, if the individual needed lunch prepared for them, but will also need help preparing for work two hours later, it doesn’t make sense for a DSP to leave and then return for the other period of help). Regardless of the cause, these periods of “down time” are essentially times where an individual could otherwise be alone and independent in their home, if certain mechanisms were put in place. Remote Supports affords such a mechanism.
With Remote Supports services, individuals who would otherwise have staff physically present can be alone and independent in their home, while preserving their safety. Indeed, the Nisonger Center at the Ohio State University conducted a study that reported the number one benefit, according to individuals receiving Remote Supports services, was safety. The second most reported benefit among individual participants of Remote Support services was independence (Tasse, Wagner, et al. 2020). While more research is necessary to determine the extent to which this service promotes increased independence among participants, among those who use the service the benefits are real.
To better illustrate these benefits, take for example the hypothetical Mr. B. Mr. B receives waiver services in Indiana, where he lives alone in his own apartment. Before Remote Supports, Mr. B received Residential Habilitation services, where a DSP would come to his apartment and help him with Activities of Daily Living. However, Mr. B made it clear during team meetings that he wanted more independence and responsibility for those ADLs. Mr. B struggled with remembering to perform basic tasks and how to accomplish them even if he remembered what he was supposed to do. To help support him, Mr. B and his team decided to use Remote Supports. With this service, Mr. B was able to exchange hours of DSP support for hours of Remote Support, during which he took charge of his ADLs. When he struggled or needed help, he would reach out to his RSP for guidance, who would either help resolve the issue or dispatch a DSP backup/responder to his home.
As CMS pushes for compliance with the HCBS Final Settings rule and promotes the adoption and implementation of person-centered practices that promote individual choice and self-determination, it appears that Remote Supports, when included in the array of potential services, is poised to help achieve those ends.
ends.
Aside from the primary benefits of increased independence to individual HCBS participants, there are also benefits for other stakeholders. Residential service providers also see benefits from integration of Remote Supports services into the care matrices of the people they serve. When more DSPs are taken away from situations with “down time” and applied as backup responders to individuals receiving Remote Supports, labor efficiency increases. Instead of idle time, DSPs can be deployed where they are truly needed for all hours with some being leveraged for those backup responder roles. Even individuals who are not suitable or do not wish to use Remote Supports can benefit from these increased efficiencies. If a DSP is no longer required to be present at the home of another individual who is utilizing Remote Supports, then they are freer to address the needs of those other individuals not using the service.
Consequently, there is significant potential for organizational-level implementation of Remote Supports services to reduce the costs associated with the high turnover of DSPs. Overtime, HR, and training expenses are a few examples of such costs that could diminish with staffing stabilization achieved in combination with expanded Remote Supports utilization (Larson, et al., 2016).
Both the direct and indirect labor benefits of Remote Supports integration have immense potential to positively impact residential providers who are suffering from the staffing crisis. It has been reported that 86 % percent of providers believe that greater applications of technology can help address the national direct support professional workforce crisis (Tanis, 2021). Effective implementation of Remote Support services across the states’ HCBS waivers has the potential to dramatically reduce reliance on in-person staff and provide a lifeline to providers struggling to meet the needs of the people they serve.
But the benefits of Remote Supports services are not limited to increased independence for individuals and labor-efficiency for residential service providers. Because of the inherent efficiencies of Remote Supports services, they can be provided more cost-effectively than in-person residential services as well. One RSP may be supporting several individuals simultaneously, thus the cost of one hour of labor is spread across many different individuals’ waivers, as opposed to situations with DSPs, where the cost of the DSP’s labor comes from the single individual’s waiver alone. The results of this cost-effectiveness means that individuals can receive a service that promotes their independence while at the same time residential providers (so long as they are allowed to capture some portion of the savings) and the state pay less per unit of service delivered.
With benefits to the individual’s served, residential providers, and states, Remote Supports is poised to become an integral part of the solution to the protracted staffing crisis facing the nation. Given the potential benefits, it is incumbent on the CMS to promote the integration of the service into the waivers of all state/provincial HCBS waivers.
How States Offer Remote Supports
The former sections have laid out the “what” and the “why” of Remote Supports. In this section we will examine the “how,” diving into the differences between different state’s efforts to implement Remote Supports services and how those respective efforts affect each state’s capacity to enjoy the benefits of the service listed above.
At least thirty states allow for Remote Supports services in some capacity. However, the service is underutilized or poorly regulated in most of these states. This section will not attempt to cover the differences among all these states. Instead, it will highlight some major differences and their respective implications. The goal is to delineate a method for adding Remote Supports services to HCBS waiver offerings in a way that benefits the most waiver participants and other stakeholders.
Indiana and Ohio: Two States with Successful Remote Supports Integrations
To benchmark effective Remote Supports integration and have a foil against which we can evaluate other attempts to integrate, we will start with an examination of the regulations of Indiana and Ohio, both of which have successfully added Remote Supports to their HCBS waivers. Indiana allows for Remote Supports in a few different ways. There is a per se service in their two waivers, Community Integration and Habilitation (CIH) and Family Supports Waivers (FSW), but the state also allows for Remote Supports to be provided on a subcontracted basis as part of residential services (Residential Habilitation and Supported Living). This arrangement allows ResHab providers to subcontract with Remote Supports providers to provide some hours of Remote Supports during downtime periods where in-person staff would otherwise be required.
There are many benefits to this method of integration, whereby subcontracting and state contracting are both allowed. Firstly, the flexibility acknowledges the inherently close nature of Remote Supports to traditional residential staffing services. Indeed, a provision of Indiana’s regulations regarding Remote Supports requires that backup staff/responders be outlined in the individual’s Person-Centered Individualized Support Plan (PCISP). The subcontracting arrangement allows for staff from an individual’s regular residential provider to be that backup staff/responder during the hours Remote Supports is being provided. Residential providers need only pay the Remote Supports provider their fee for Remote Supports services out of the typical residential daily rate they are reimbursed for from the state.
Secondly, Indiana and Ohio’s methods for allowing Remote Supports provide a financial incentive for providers to adopt the service. Take a hypothetical provider in Indiana for example. For every hour of downtime, they switch from in-person staffing to Remote Supports, they are able to not pay a staff person but instead pay the Remote Support provider’s fee. Because of the inherent efficiencies of Remote Supports providers, they can provide the service at a rate consistently lower than that of in-person staff. As such, residential providers in Indiana make more money when they switch downtime hours from in-person staffing to Remote Supports. This financial incentive has proven a key aspect of successful Remote Supports integrations into HCBS waivers, and the absence of such a financial incentive has likewise generated tepid responses from providers.
Thirdly, Indiana and Ohio both separate out their Remote Supports services from other technology-based services, such as Assistive Technology and Environmental Modifications. This separation has two positive effects (1) it allows Remote Supports to be regulated separately, without the relatively loose conditions, restrictions, and limitations of PERS or AT, and thus, appropriately, and (2) it recognizes the fact that, given the cost-effectiveness of Remote Supports to the state, Remote Supports services shouldn’t be capped similarly to AT or Environmental Mods. These two effects of separating Remote Supports as a service have very serious implications for workability of the service for state stakeholders, including individual HCBS participants.
Fourth, Indiana and Ohio, by allowing subcontracting with providers in addition to state contracting without residential provider affiliation, allow the broadest possible access to Remote Supports services. Individuals on Indiana’s Family Supports Waiver (FSW) often do not receive residential services or do not have a residential service provider. If Indiana only allowed for the subcontracting route, these individuals’ access to the service would be limited. However, by providing a path by which Remote Supports providers can contract with the state directly, they allow these individuals to choose to use the service if it is appropriate.
Finally, Indiana and Ohio’s implementation of Remote Supports into waiver services include provisions for ensuring the preservation of privacy of the individual, including provisions for informed consent of all residents within the home. Examples of these regulations for Indiana and Ohio can be found in the Indiana CIH Waiver Amendment document and Ohio Administrative Code 5123-9-35(D)(6), respectively.
Altogether there are seven key elements that Indiana and Ohio’s implementation of Remote Supports into their HCBS waiver possesses:
(1) Separate definitions for Remote Supports, AT, and other technology-based HCBS services.
(2) Provisions for Remote Supports providers to both subcontract with residential service providers to provide services to individuals the residential provider serves and to contract with the state to provide services to individuals who do not have a residential services provider, such as individuals on self-determination waivers, individuals in family homes, etc.
(3) Financial incentives for residential providers to adopt Remote Support services and push for their integration into individuals’ PCISPs.
(4) Regulations that mitigate the risks associated with Remote Supports services.
(5) Funding/reimbursement models that do not arbitrarily cap reimbursement for Remote Supports services.
(6) Funding/reimbursement models that do not combine reimbursement funds for Remote Supports with reimbursement funds for AT and other technology-based HCBS services.
(7) Provisions for informed consent and privacy considerations that support an individual’s right to privacy and to choose whether Remote Supports will include live video.
Examples of State Integrations that Restrict Benefits
In this section, the drawbacks of state integration attempts that do not possess the above properties will be outlined.
To begin, consider a state which has not separated Remote Supports from their Assistive Technology HCBS service definition or has combined it with other technology-based services to create an omnibus technology service. This inherently limits the state’s ability to regulate each discrete subservice at a waiver level because definitions, limitations, and approved provider requirements are set during waiver amendment periods. What’s more, states inherently limit their capacity to fine tune reimbursement amounts when technologies are lumped together. For example, PERS often cost around thirty to fifty dollars per month to operate. Reimbursement for PERS services significantly above that mark means the state is overpaying for those services. Similarly, Remote Supports can cost anywhere from two dollars to eight dollars per hour of services rendered. If a state’s reimbursement methodology caps the omnibus tech service reimbursement rate at forty dollars per month, then the individual is severely restricted in the number of hours of Remote Supports they can use.
Separating these services at once allows states to reimburse and regulate each one appropriately, which not only improves the safety of each constituent services but saves the state and CMS funds in the long term.
Secondly, states that do not allow Remote Supports providers to provide their services on a sub-contractual basis with residential providers, in addition to a state contracting arrangement. introduce obstacles to Remote Supports integration. For states with only subcontracting, individuals who are not associated with a residential provider are denied access to the service. For many states that only allow state contracting, suboptimal regulations (including provider enrollment processes designed for residential service providers, not Remote Supports providers) often present major administrative obstacles for Remote Supports providers.
For states to have parity among the populations they serve with regard to access to Remote Supports services and their benefits, both subcontracting and state contracting should be allowed. In the case of the former, regulations regarding the provisions of Remote Supports should still be in place to ensure the core components are addressed and safety of the individual is maintained. In state contracting situations, attention must be given to the fundamental differences between providers of Remote Support services and residential service providers. Provider enrollment processes and requirements, including required training for staff, often include items which are not applicable to remote service provision. Examples include water temperature regulation (in an individual’s home), hazardous and toxic chemical handling (in an individual’s home), approved restraints, and handling of bloodborne pathogens. Each of these training items do not apply to remote service provision, and thus should not be required of Remote Supports providers.
In addition to refining provider enrollment and training requirements to more appropriately fit the nature of Remote Supports services, we also urge states to understand the interstate nature of Remote Supports service provision. An RSP could, at any time, be supporting individuals from five different states. This is fundamentally different than most other service models. That means RSPs are required to take five different versions of Abuse, Neglect, and Exploitation training to satisfy each of the different states’ training requirements. We understand the necessity of this training but urge CMS to recommend that states accept other state’s training and training evidence as sufficient for their own training requirements. Without such interoperability, the growth of Remote Supports will continue to be hindered at the Remote Support provider level. Newly onboarded RSPs will be required to take ten, fifteen, or even twenty separate but ultimately equivalent training on common subjects such as Abuse, Neglect, and Exploitation, Rights of People with Disabilities, and so on.
Thirdly, many states do not include necessary regulations to ensure that the provision of Remote Supports is done safely. Key aspects of quality Remote Supports service definitions, including the necessity of a live monitoring station, requirements for redundant phone and internet connections, requirements for two-way audio or video communication, requirements for a backup generator, battery backups, and HIPAA-compliant IT systems, are often left out in the interest of removing barriers to technology integration. While we do agree that some of these requirements are not necessary for certain types of technologies/technology-based services, we urge states to include them for Remote Supports specifically. Other services, so long as they are separated out in the waiver, can be regulated according to their own needs. But the nature of Remote Supports, a service which connects individuals to RSPs in real time, requires that measures be taken to ensure that Remote Support systems have adequate uptimes and that, in the event of catastrophic failure, backup measures are in place to ensure individuals can receive in-person support on short notice. It is the presence of these key infrastructure requirements that have allowed Remote Supports to be successful as a service, and we urge CMS to include such requirements in their guidance to states about Remote Supports implementation.
Finally, there are two significant pitfalls that states fall into when it comes to how states define and reimburse for Remote Supports services.
Firstly, if it is understood that Remote Supports are a service that is intended to reduce reliance on in-person staff and that Remote Supports are, unit for unit, more cost-effective than residential staffing services, then it follows that there should be no cap on the number of hours which can be exchanged from residential services to Remote Supports. Ohio reimburses Homemaker, Personal Care (HPC) services at $23.34/hour and Remote Supports services with paid backup support (RS) at $10.24/hour. For every hour switched from HPC to RS, the state saves $13.10/hour. For just one individual exchanging 8 hours of HPC for RS daily, the annualized savings for the state are $38,252. Given this, the state of Ohio does not cap the number of units of RS that can be utilized, so long as it remains appropriate given a person-centered examination of the individual’s goals and intended outcomes.
Unfortunately, some states do cap Remote Supports services by placing the funds available to reimburse the service in the same bucket as funds for Assistive Technology, Environmental Modifications, etc. While it makes sense to cap AT funds, if we understand AT to be discrete devices aimed at improving functional capabilities, it does not, as we’ve demonstrated above, make sense to cap Remote Supports.
A second unintended consequence of putting Remote Supports and assistive technology monies in the same capped fund is that individuals are often forced to choose between one or the other. This is not necessary, and in fact restrictive to individuals. It is possible a person could need some AT devices, such as a screen reader, and also benefit from Remote Supports. Forcing them to choose between AT and Remote Supports puts non-competing and non-duplicative services into a competing framework.
Conclusion
Over the many years CAIRSS members have been providing Remote Supports services, we have experienced many different permutations of state efforts to implement Remote Support services and other technologies into their HCBS waiver systems. It is our collective belief that not all implementation efforts are equal, even though they are all well-intentioned.
As states, provider organizations, and other stakeholders finalize their transition into compliance with the HCBS Final Settings Rule, it’s important that technology-based services are available as a viable and safe option to increase an individual’s choice of setting. The capacity for Remote Supports services and others to assist in this transition should not be constrained by the way states implement these services in their HCBS waivers.
The Centers for Medicare and Medicaid Services is in a unique position to offer federal guidance on Remote Supports integration to help avoid past mistakes and to provide states the information they need to competently integrate the service in a way that removes unnecessary barriers for individual use of the service, removes obstacles for service provision, and promotes competition among Remote Support providers to ensure that quality and price remain competitive and advantageous to states.
Recommendations
1. CMS formally recommends all states offer Remote Supports as an allowable service within their HCBS waivers to alleviate the effects of the staffing shortage and improve outcomes for participants.
2. CMS creates and promulgates a definition for Remote Supports services.
3. CMS creates guidelines related to the implementation of Remote Supports service definitions to remove administrative and operational barriers to service and ensure equal access to Remote Supports services among all HCBS participants.
4. Relating to the above recommendation, CMS urges states to accept interoperable training standards to reduce training redundancies.
References
ANCOR. (2022). (rep.). The State of America's Direct Support Workforce Crisis 2022. ANCOR.
Larson, S.A., Tolbize, M.S.A., Kim, O., and York, B. (2016). Direct Support Professional Turnover Costs in Small Group Homes: A Case Study. Minneapolis: University of Minnesota, Research and Training Center on Community Living.
National Core Indicators. (2022). National Core Indicators Intellectual and Developmental Disabilities 2020 Staff Stability Survey Report. https://www.nationalcoreindicators.org/resources/staff-stability-survey/
Richter, B. (2021, November 11). What are Remote Supports? - CAIRSS . CAIRSS. Retrieved March 7, 2023, from https://www.cairss.org/positions/project-four-2jzmp
Tanis, S. (2021). (rep.). Perspectives from Intellectual and Developmental Disability Services Providers Across the Nation. ANCOR.
Tassé, M. J., Wagner, J. B., & Kim, M. (2020). Using technology and remote support services to promote independent living of adults with intellectual disability and related developmental disabilities. Journal of Applied Research in Intellectual Disabilities, 33(3), 640–647. https://doi.org/10.1111/jar.12709
Wagner, J. B., Tassé, M. J., & Ornan, G. (2022). Implementation of Remote Support Services: pre‐covid ‐19. Journal of Policy and Practice in Intellectual Disabilities, 19(4), 340–349. https://doi.org/10.1111/jppi.12420