Home and community-based services (HCBS) provide opportunities for individuals with disabilities and older adults to receive services in their own home or community. On January 16, 2014, the Centers for Medicare & Medicaid Services (CMS) published a final rule that sets forth new requirements for states using Medicaid funds to pay for HCBS, supports enhanced quality in HCBS programs, and adds protections for individuals receiving these services. In addition, the rule reflects the intent of CMS to ensure that individuals receiving services and supports through Medicaid’s HCBS programs have full access to the benefits of community living and are able to receive services in the most integrated setting. ACL is highlighting examples of a promising practice for employment benefits designed to meet the needs of individuals, promote integrated employment, and comply with requirements of the HCBS settings rule and the Supreme Court’s Olmstead v. L.C. ruling. With regard to Medicaid-funded employment services it is the state’s responsibility to ensure that 1915(c) HCBS supported employment waiver services are furnished to a waiver participant to the extent that they are not available as vocational rehabilitation services funded under section 110 of the Rehabilitation Act of 1973. Read our first post in this series to learn about the Arc of Washington’s efforts to transition youth into integrated employment.
Twenty-five years ago Community Link in Colorado developed a strategic plan to convert their sheltered workshops to a more integrated employment support model.
According to Bob Lawhead, Chief Executive Officer of Colorado Community Link and President of the Colorado Association of People Supporting Employment First, the strategic plan was initiated after the majority of participants expressed a desire for community employment, with only 14% of those served choosing a segregated workshop option. This preference drove the change process and persuaded the board of directors, agency staff, family members, and people receiving services that conversion from segregated to integrated services made sense. In the years following implementation of the strategic plan, people waiting to be connected to employment may have been placed into a day service program with small groups funded by the state‘s HCBS waiver program. That service offered volunteer experiences to small groups of individuals in community settings. The goal was to provide individuals with opportunities for work and social skill enhancement and to facilitate relationship-building between participants and nondisabled community members.
However, the program did not result in an effective pathway to employment as the agency had hoped. The agency’s experience with congregate models has been challenging as many got “stuck” in the transitional phase involving group activities, whether volunteer or paid employment, and were not ready to proceed to integrated employment. According to Lawhead, the supported employment service rate made it cost prohibitive to provide individual, non-group employment supports and did not allow for individualized choice-driven community participation. Building on these lessons, Community Link was able to develop a new model which has allowed individuals to experience improved employment outcomes. Under this model, Community Link offers career-counseling, discovery-based assessment, job development, job placement, on the job training, and ongoing employment support for individual job seekers with intellectual and developmental disabilities. And they have found that the more individualized the support, the greater the likelihood of a successful employment outcome.
Community Link historically received two thirds of their employment service funding from Medicaid waiver services and one third from Vocational Rehabilitation (VR). Presently, successfully employed individuals receive services which are funded in sequence from Medicaid and VR. Discovery and writing an individual job development plan is paid for through the HCBS waiver. After that the waiver support for employment stops and VR funding support picks up. Customized job development (the most resource intensive activity), job coaching, and job stabilization are paid for using VR funding. Once stabilization occurs, when the job coach is spending less than one third of scheduled job hours with the individual, the waiver employment services resume.
Lawhead believes the state made significant progress recently by changing their VR vendor payment schedule by significantly improving funding for customized job development. Lawhead feels that this change along with enhanced HCBS waiver funding for supported employment services will result in better employment outcomes for the individuals receiving their services and supports.
He and others in Colorado are presently working on Employment First legislation that would align state agencies to prioritize competitive integrated employment services for people with disabilities, with a focus on HCBS waiver program participants who experience intellectual and developmental disabilities (IDD). This legislation, introduced in early 2016, seeks to align Colorado’s IDD services with the Olmstead ruling and CMS’ HCBS rule requirements by affirmatively expanding integrated employment outcomes.
ACL is interested in hearing from states, providers, and advocates working on integrated employment. Share your successes, challenges, and questions by e-mailing email@example.com.