The Problem with Assessments

As Appendix K flexibilities are rolled back and providers continue to face staffing shortages and high turnover, more states and residential provider organizations are looking to technology to help maintain and improve services. Remote supports, as one of the available options for many, presents an opportunity to do just that. However, implementation on an organization-wide scale presents many practical challenges, one of which is assessments.

Some states, such as Massachusetts and Pennsylvania, provide their own technology assessments aimed at helping facilitate the integration of remote supports and assistive technology in peoples' person-centered support plans. Often, these assessments prompt case managers/care coordinators/etc. to detail the person's goals, identify potential technology products or services to help reach those goals, and to isolate risks associated with the introduction of said technologies. There are three common problems with this approach.

The first problem centers around a lingering problem within efforts at technology integration. That is, who needs to know? Who needs to know the particulars of the technology, how it will positively impact the person, and the risks associated with use? On its face, this seems like a trivial question; the answer should be everyone, the individual, the case manager/support coordinator, the residential provider, the behavioral specialist, the family/guardians and so on. For some tech-based solutions, everyone can know those three features. But for others, particularly remote supports, the connection between the discrete tech devices and the outcomes they are intended to bring about is less clear.

Wheelchairs enhance mobility, allowing individuals to access areas they would otherwise need assistance to reach. To all the stakeholders mentioned above, this is clear cut. Even the risks associated with wheelchairs seem easy to grasp. But remote supports are less clear. One motion sensor may not be tied to one intended outcome. Rather, it’s part of a constellation of devices intended to support a service that brings about outcomes. Assessments that require stakeholders other than remote supports providers to make remote supports technology determinations, such as what sensors will be required and where, place an undue burden on already overworked personnel. Instead, they should focus on establishing outcomes and prompting remote supports providers to determine the appropriate way to construct those systems.

Secondly, there many current assessments for Assistive Technology and Remote Supports do not differentiate between appropriateness of the service and acceptable levels of risk at different times during the day. It may be clear that a person wouldn’t be suitable for remote supports during daytime hours, but during sleeping hours or other periods of inactivity, they could be used successfully. Assessments that lack the capacity to differentiate between periods of activity and inactivity, based on each individual’s actual routines, fall short of being truly person-centered and present obstacles to remote supports integration.

The third problem concerns how determinations are made, either at the state, case management, residential provider, or family/guardian level about acceptable and unacceptable levels of risk. These determinations often err on the side of precaution. However, there is not yet any demonstrable way of determining how a given individual will react to expanded independence through remote supports. Anecdotally, the members of CAIRSS can attest to numerous situations where individuals who, according to conventional thinking, would be too high-risk for remote supports, going on to flourish with more alone time. As an example, many individuals with incidences of violence or aggression toward staff and housemates see a reduction in that behavior when their home becomes more theirs, with fewer hours of staff presence and fewer roommates. Assessments can't accurately predict the unexpected positive outcomes of remote supports integration into individuals' lives. More work has to be done to determine how to safely evaluate individuals for remote supports suitability without precluding them from enjoying the dignity of risk associated with trying a new support that may fail.

CAIRSS recommends that stakeholders adopt a new framework for how they go about assessing individuals for remote supports. Namely, we urge them to accept presumptive fitness, the idea that individuals are suitable for more independence through remote supports until concrete evidence or experience is produced to the contrary. This recommendation echoes the broader "Tech First" sentiments adopted by many states, but instead of just looking at whether tech can help a person before assuming staff is necessary, we argue that stakeholders should assume the individual is suitable for the service until it is proven otherwise.