Comprehensive Training for Direct Care Workers in Texas' Statewide Support Program for People who are Deafblind with Multiple Disabilities

by
David Wiley and Kate Moss, Texas Deafblind Outreach, TSBVI
Steve Schoen, Texas Rehabilitation Commission

This paper was originally published in "Let's Celebrate our Harmony Together", the Workshop Proceedings of the 6^th Canadian Conference on Deafblindness. The Canadian Deafblind and Rubella Association. 1998.

Since the original publication, Stephen Schoen and the Texas Medicaid Waiver for Individuals who are Deafblind with Multiple Disabilities have moved from the Texas Rehabilitation Commission to the Texas Department of Human Services. The services, regulations, and philosophy of the program have remained the same. As of 2002, the program serves approximately 140 individuals.

The Texas Rehabilitation Commission (TRC) administers a Medicaid Waiver program designed specifically to provide residential support in the community for adults who are deafblind with additional disabilities. This program offers a wide array of services, including among others: support and training for people living in their own or their families home; small group home living; day activities; orientation and mobility training; nursing and therapies; intervener; and adaptive equipment. All service recipients must be deafblind with additional disabilities, eighteen years of age or older, and eligible for Medicaid. Services are provided by program vendors located in a number of communities all around the state, with funding and oversight provided by TRC.

In designing the program Texas Rehabilitation Commission felt there was a need to make sure program providers trained direct care staff in the unique needs of people who are deafblind. Program regulations were written to require training of all staff on the basics of working with individuals with deafblindness. To assist providers in improving the quality of the training, Texas Rehabilitation Commission determined there was a need for a standard training manual to be used program-wide. After exploring some existing training materials, the program administrator at Texas Rehabilitation Commission felt the need to create a manual which focuses on the specific population served by the waiver, is targeted to paraprofessional direct care workers, and would take approximately twenty hours of training time to complete.

Texas Rehabilitation Commission asked Texas Deafblind Outreach at Texas School for the Blind and Visually Impaired (Texas' 307.11 project) to join TRC in developing a series of training modules for use by service providers. Texas Deafblind Outreach has worked with Texas Rehabilitation Commission's deafblind program for many years in a variety of circumstances and is familiar with the program. For example, Texas Deafblind Outreach has a history of working with a number of current adult Texas Rehabilitation Commission clients during their school years. Texas Deafblind Outreach has worked with a number of different Texas Rehabilitation Commission program providers by assisting students who were deafblind make the transition from school to community life. Texas Deafblind Outreach has also assisted Texas Rehabilitation Commission in training and surveying program providers. Based on this history, Texas Rehabilitation Commission and Texas Deafblind Outreach met to plan the content for the modules reflecting training needs observed at the service sites.

Six topics were selected as important to the basic training of all direct care workers. These six training modules are: etiologies of deafblindness; vision, hearing, and the impact of deafblindness; orientation and mobility; communication; active participation in daily life; and addressing challenging behavior. The communication section is considered the most crucial, and by itself comprises the majority of the manual. These topics were selected to provide staff with background information, as well as specific strategies for working with individuals who are deafblind with additional disabilities.

In order to make the manual useful to providers with a range of experience and knowledge about deafblindness, the training manual was designed with both training outlines and supplemental readings to increase the content knowledge of the on

site trainers. The manual also contains suggested handouts, overhead transparencies, and suggestions for further reading. Many group exercises and simulation experiences were included to make the training experience more engaging. Additionally, some of the modules include guided client observations. These are meant to tie the training back to the actual clients with whom the staff works. The modules were written to be used for training paraprofessional direct care workers who don't necessarily have any. prior experience with providing support to people who are deafblind.

The module dealing with etiologies is brief and covers many common causes of deafblindness. It is primarily designed to make trainees aware that different etiologies have important implications in planning for and delivering services in the areas of health management, communication, behavior, etc. It stresses the importance of researching the etiology of every person they serve.

The module on vision, hearing, and deafblindness provides overview information on how vision and hearing work, and what can go wrong. The emphasis is on understanding the functional implications of sensory impairments. A key point is the need for service providers to provide information not otherwise accessible to a person who is deafblind. The training outline includes exercises in which the participants need to complete various tasks under simulation of deafblindness. The goal of these simulations is to help staff understand the kinds of support and information that will best help the people with whom they are working. Texas Rehabilitation Commission also supplied each program site with low vision simulation kits. A videotape, produced by Texas Deafblind Outreach for use in this module, helps illustrate a high frequency hearing loss, and how the absence of visual information further limits the ability to understand speech. Each site was also given a copy of this tape.

The module on orientation and mobility clearly states that O & M training needs to be provided by a certified O & M specialist. The training does however provide information on the basics of sighted guide, and how to organize space to facilitate independent movement. Training participants are given the opportunity to practice good sighted guide techniques.

The communication module is the largest in the manual. Trainees receive a background in communication basics, such as communication forms, functions, and topics. The training in this module includes an examination of how people use and understand a wide variety of forms ranging from very concrete (natural gestures and objects) to more abstract (sign and speech). There is a focus on the importance of addressing basic communication rights in the provision of services. The module also covers facilitating communication between people who are deafblind and others in the community. High-tech and low-tech communication aids and technology are also demonstrated. A videotape on the basics of using communication calendars was developed by Texas Deafblind Outreach and given to each program site. Many group exercises and games help the principles come to life for the trainees.

The module on active participation helps staff understand how to support people who are deafblind to become more involved with the activities of daily living. The training emphasizes how a greater participation in activities leads to a more full and satisfying life. Strategies are given which aid the staff in supporting more independence for the people with whom they are working. Enhancing recreation and leisure time for individuals with deafblindness is also covered.

Behavior is frequently communication for people who are deafblind with additional disabilities; communication is interactional. This particular module highlights strategies which help staff to proactively address difficult behaviors by searching for the message in the behavior. This is demonstrated through group problem solving exercises. This module stresses: (1) the importance of eliminating from the environment things or actions that cause troubling behavior; and (2) teaching alternative and more acceptable communication strategies. The outline also covers the need to reduce anxiety by making situations and expectations more clear and understandable. Providing more choice and control in order to reduce frustration and improve quality of life is discussed as well.

Texas Rehabilitation Commission organizes "train the trainer" workshops in which administrators from all the various service sites gather to learn more about the training manual. They are led through the outline and shown how to facilitate the exercises and games. These administrators then have the responsibility to conduct training on their individual sites. Texas Deafblind Outreach from Texas School for the Blind and Visually Impaired helps with these train the trainer meetings, and is available to travel to the sites if there is the need for more training support.

The Texas Rehabilitation Commission program monitoring documents were written to conform with these training goals. Annual provider surveys help insure that staff training results in higher quality services. The Texas Rehabilitation Commission program specialist and other parties familiar with quality services to people who are deafblind observe direct care workers during these surveys to see if the skills and philosophies of the required training are put into practice. This is more effective than simply looking at attendance rosters or carrying out other paperwork monitoring.

Since the introduction of the Texas Rehabilitation Commission Deafblind Program Training Manual there has been improvement in the training staff around the state are receiving. The overall goal is continuing improvement of services to Texans who are deafblind with additional disabilities. The coordination of resources from the Texas Rehabilitation Commission and Texas Deafblind Outreach at Texas School for the Blind and Visually Impaired will hopefully lead to continuing achievement of this goal.