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Supported Employment: Payment and Other Incentives by HC111211094146

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									       FDDC Contract Number 661EM07
Supported Employment Incentive Payment Study
           Deliverable 5 Submittal




                     Prepared by
           Human Systems and Outcomes, Inc.
                Edited by Celeste Putnam, M.S.




                     November 13, 2007




                             Contents:
           • Final White Paper and Recommendations
                   • Project Executive Summary
                      • Evaluation Component
                                                                 Table of Contents

Introduction ................................................................................................................................................... 1
Literature Review.......................................................................................................................................... 2
   Financial Disincentives ............................................................................................................................. 2
   High Performing States ............................................................................................................................. 5
   Structuring Financing Strategies ............................................................................................................... 6
   Florida’s Issues Associated with Payments for Supported Employment .................................................. 9
      Vocational Rehabilitation ..................................................................................................................... 9
      Agency for Persons with Disabilities .................................................................................................. 11
Review of Ten States ................................................................................................................................... 14
   Developmental Disabilities ..................................................................................................................... 15
      Fee-for-Service Payments Using a Set State Rate ............................................................................... 15
      Fee-for-Service through Contracted Rates ......................................................................................... 16
      Individual Rates and Provider Rates Combined .................................................................................. 17
      Contracts to Provide a Range of Services ........................................................................................... 17
      Payment Incentives ............................................................................................................................. 18
      Other Mechanisms Used to Promote Supported Employment .......................................................... 18
   Vocational Rehabilitation........................................................................................................................ 19
      Summary of Vocational Rehabilitation Funding ................................................................................. 19
      Comments on Payments and Incentives ............................................................................................. 19
   Interagency Collaborations ..................................................................................................................... 20
Transitioning Youth and Young Adults from School to Work ..................................................................... 21
Issues and Options ...................................................................................................................................... 23
   Vocational Rehabilitation........................................................................................................................ 23
      Need for Upfront Payment or Assessment ......................................................................................... 23
      Need to Provide Incentives for Vocational Rehabilitation Counselors ............................................... 24
      The Rate Structure Should Be Designed to Recognize Levels of Severity........................................... 24
      Opportunities for Professional Growth Are Needed .......................................................................... 25
      Need to Use More Natural Supports for Extended Services .............................................................. 25
      Need to Clarify Flow between Time-limited and Extended Services .................................................. 25
   Developmental Disabilities ..................................................................................................................... 26
      Need to Modify the Quarter-Hour Payment Structure ...................................................................... 26
      Extended Services Do Not Give Providers Sustained Income ............................................................. 26
      Support Coordinators May Not Always Encourage Supported Employment ..................................... 27
      Transportation Is a Problem ............................................................................................................... 27
      Non-work Hour Supports Must Be Addressed.................................................................................... 28
      Extended Employment May Not Be Available for Transitioning Students ......................................... 28
Recommendations ...................................................................................................................................... 30
Recommendations Regarding Phase-In of Changes and Safeguards ......................................................... 31
Safeguards................................................................................................................................................... 33
Additional Follow-up ................................................................................................................................... 33
References .................................................................................................................................................. 34
   Individuals Interviewed ........................................................................................................................... 36
   Group Interview with Florida Association of Rehabilitation Facilities .................................................... 36
   Individuals Who Participated by Telephone ........................................................................................... 36
Appendix A: Ten States Interview Summaries ......................................................................................... A-1
Appendix B: Sample Interagency Agreements..........................................................................................B-1

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                                         Introduction

         The Florida Developmental Disabilities Council funded the Supported Employment
Payment and Incentive Study to examine best practices in other states for providing streamlined
supported employment services across agency lines with a uniform payment and incentive
system. Supported Employment is a program designed to assist persons with serious disabilities
to obtain competitive, community-integrated employment. Supported Employment was first
authorized through the Rehabilitation Act Amendments of 1986 and, since that time, has been a
major avenue for employment for persons with developmental disabilities. The major premise of
the service is that many persons with significant disabilities need additional support at the job
site to secure a job and work successfully. These supports can be provided by employment
specialists, mentors, coworkers, and employers (Revell, Kregel, Wehman, and Bond, 2000).

        Supported employment is provided in two phases. Phase One is a time-limited
employment service, primarily funded by state vocational rehabilitation programs, which usually
includes job development, training, and job placement. Phase Two is known as extended or
follow-along services and includes periodic job skills reinforcement and other supports necessary
for job retention. It is usually funded by the developmental disability agency (West, Johnson,
Cone, Hernandez, & Revell, 1998).

        Successful implementation of supported employment services requires collaboration
between Vocational Rehabilitation and the developmental disability agency to ensure that there
is a continuous flow of uninterrupted services. The agencies should be aligned in their values,
principles, and practices to encourage providers to render supported employment services.

        Florida has been providing supported employment services to persons with
developmental disabilities since the mid-1980s. Developmental Services (now Agency for
Persons with Disabilities) developed collaborative working relationships with Vocational
Rehabilitation to provide for job development and placement, while Developmental Services
provided the job retention services (Phase Two). This working relationship has persisted across
the decades, allowing supported employment to continue to be an important component of the
service delivery system.

       Vocational Rehabilitation, Medicaid, the Agency for Persons with Disabilities, and the
Florida Developmental Disabilities Council want to see an increase in the provision of integrated
supported employment. A literature review was conducted to provide additional insight
regarding how financial issues have impacted the provision of supported employment services
and a better understanding of how financial issues should be addressed.




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                                       Literature Review

                                     Financial Disincentives

       Supported employment grew rapidly from the mid-1980s to the mid-1990s, increasing
supports to persons with disabilities by over 200% (Wehman & Kregel, 1995). The program
continues to grow, but supported employment proponents are concerned that the growth has not
surpassed the growth in segregated adult day programs and sheltered workshops. There have
been numerous issues documented in the literature regarding the contributing factors to the
predominate use of segregated environments. Several of these include financial issues.

         Some of the constraints that originally impacted supported employment have been
resolved over the last decade. Until the Balanced Budget Act of 1997, there were eligibility
restrictions that prevented the provision of supported employment through the Medicaid Home
and Community Based Waiver to persons who had never been institutionalized. The Balanced
Budget Act of 1997 removed these restrictions, making the service available to a much broader
population (West et al., 2002). Additional federal actions—such as President Bush’s New
Freedom Initiative—emphasized competitive integrated employment for persons with
disabilities. The Rehabilitation Services Administration of the U. S. Department of Education in
2001 amended their regulations governing the State Vocational Rehabilitation Program, defining
an employment outcome as employment in an integrated setting (State Vocational Rehabilitation
Final Rule, January 22, 2001). These two federal policy changes, combined with the Americans
with Disabilities Act of 1990 and the Olmstead Supreme Court decision supporting community
inclusion, provided additional impetus for integrated supported employment.

        States, including Florida, are also facing fiscal challenges, with many more persons with
developmental disabilities needing services, and with youth transitioning from schools requiring
employment programs at an ever-increasing rate. Supported employment not only provides for
community integration and personal income, but also has been found to be cost-efficient.
Cimera in 1998 reported that, regardless of the severity or number of disabilities, supported
employment was cost-efficient with respect to worker wages, tax payments, and overall social
outcomes. In 2000, Revell, Kregel, Wehman, and Bond examined cost effectiveness through an
analysis of the cost associated with achieving meaningful outcomes. The authors described how
two states—Massachusetts and Oklahoma—provided funding for supported employment. They
concluded that supported employment can be cost effective, though this is not always the case.
According to the authors, what makes the difference is the competence of the providers.

        Yet even with this focus on integrated employment and efficiency through supported
employment services, many persons with developmental disabilities continue to work in
segregated environments, such as sheltered workshops or other day programs. In Fiscal Year
2003, only 26% of individuals receiving community-based supports and services worked, and
those that did worked for limited hours and low wages (Metzel, Boeltzig, Butterworth, Sulewski,


                                                2
& Gilmore, 2007). The Institute for Community Inclusion reported that state agencies that
provide supports for adults with disabilities use facility-based programs 59% of the time and that
the expansion of supported integrated employment has slowed. For the most part, states continue
to expand their facility-based adult programs for persons with developmental disabilities (Hall,
Butterworth, Winsor, Gilmore, & Metzel, 2003).

        In 1999, West, Revell, Kregel, and Bricout showed that the policy restricting supported
employment services to persons without prior institutionalization was negatively impacting
supported employment services through the Waiver. Given that these restrictions were
eliminated in 1997, supported employment programs through the Waiver were expected to
significantly increase. West et al. completed a national survey of state developmental disability
agencies in 2002 regarding the use of the Medicaid Home and Community Based Waiver to fund
supported employment before and after the policy changes in the Balanced Budget Act of 1997.
The researchers found that supported employment was growing faster than other day programs;
however, they also determined that less than 16% of those receiving day habilitation services
through the Waiver received supported employment and that the supports only accounted for
12% of the expenditures.

         In an attempt to explain their findings, the researchers returned to their 1999 study in
which two other barriers were reported by at least one fourth of the respondents: (a) difficult
billing and documentation requirements, and (b) low reimbursement rates. In the 2002 follow-up
article, the researchers speculated that financing issues may remain one of the disincentives to
providing supported employment through the Waiver and that Waiver reimbursement rates to
service providers continue to be low in comparison to rates that were paid by vocational
rehabilitation agencies. The researchers stated that these factors may limit the providers’ interest
in providing supported employment services through the Waiver. The authors recommended
that states address financial disincentives to promote integrated work opportunities.

         Other investigators have looked not just at the predominance of segregated settings, but
also at the desired outcomes of the Supported Employment Program. Mank, Cioffi, and
Yovanoff (2003) reviewed supported employment outcomes to determine if there has been
quality improvement over the last decade. They found that there was a lack of significant change
in wage levels, integration, and the types of jobs held by persons with developmental disabilities.
The researchers stated that the lack of change in these variables may be due to larger system
issues, noting that the structure and funding of supported employment may make it difficult for
providers to invest in important components of the supports. It takes longer to find jobs that are
full time and that have benefits, requiring more work assessments, job development, job
exploration, and job matching. If the payment structure does not acknowledge this additional
effort, there will be no financial incentives for helping people choose, get, and keep full-time
jobs. The authors note that other system issues are at play as well. Loss of benefits—especially
insurance—is of major concern to individuals and their families, as is transportation and
supervision during non-work hours.

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        It should be noted that the Medicaid Buy-in Option provides a solution to the insurance
dilemma by permitting states to continue to provide Medicaid benefits to persons if they lose
their benefits due to income increases through work. The fear of loss of insurance benefits is
repeatedly mentioned as a disincentive to work. Although not directly related to financing
strategies, the Medicaid Buy-In is a financial investment that states can make to address this
major barrier to employment. As of 2004, 39 states had implemented or were planning to
implement the Medicaid Buy-In program (Sulewski, Gilmore, & Foley, 2006).

        Wehman, Revell, and Brooke (2003) examined the issues of availability of competitive
employment for individuals with significant disabilities compared to segregated day and work
services. In this paper, the authors addressed several factors that impact the availability and
quality of supported employment, examining both values and quality indicators. They assert that
the goal of supported employment is more than simply finding jobs for people with significant
disabilities, and that it should include a career focus. The authors believe that the number of
hours worked on a weekly basis is considered a quality indicator for a supported employment
program, stating that when persons receiving supported employment work less than 30 hours, the
programs are faced with how to fill the non-work hours. This can result in turning to segregated
programs for the needed activities and assistance. The authors recommend that funding agencies
consider rewarding achievement of employment outcomes of 30 hours or more per week with
funding incentives.

        Wehman, Revell, and Brooke (2003) also addressed the importance of a well-coordinated
job retention system. Unlike job placement, job retention services are often provided by non-
Vocational Rehabilitation funding sources, such as the Medicaid Home and Community Based
Waiver. According to the authors, there is strong evidence that ongoing supports after job
placement and stabilization are required. Unfortunately, they have found that supported
employment providers face substantial challenges in providing job retention supports after the
Vocational Rehabilitation agency closes the case. Access to funding appears to be one of the key
issues. According to the authors, agency funding frequently does not cover the costs of
providing these services. West, Wehman, and Revell (2002) noted that maintaining supports
after vocational rehabilitation services is key to addressing work-related problems, and that the
amount of necessary contact hours may need to be increased during the three to six months after
successful job placement. They also noted that non-Vocational Rehabilitation resources are used
predominately for these services and that these are often inadequate to address the need.

         Novak, Rogan, Mank, and DiLeo (2003) found, in their comprehensive survey of 50
states, that respondents overwhelmingly reported that inadequate long-term funding discouraged
supported employment. Other disincentives noted are as follows:

      It is less expensive for community rehabilitation providers to render segregated services.
      The funding source available for segregated services is more stable than funding sources
       available for supported employment services.

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      Programs that provide follow-along services (extended services) traditionally fund
       segregated programs.

Also noted in the study were fiscal incentives established by states. Examples are as follows:

      Vocational Rehabilitation provides upfront funding to community rehabilitation providers
       for job development and placement services in some states.
      Vocational Rehabilitation rate structure in 11 states favors integrated services. In some
       states, the hourly reimbursement rate for supported employment services is significantly
       higher than the daily rate for sheltered work.
      Any new funding made available through the state Vocational Rehabilitation agency or
       Developmental Disabilities is restricted to integrated services.
      If a consumer leaves a segregated program, the provider loses the “slot.”
      Some states offer bonuses for community employment outcomes.

                                     High Performing States

        To help move the supported employment agenda forward, several researchers have
documented best practices in the areas of system change and financing. In 2003, Hall,
Butterworth, Gilmore, and Metzel completed a study of high-performing states in integrated
employment for persons with disabilities. They ranked these states according to the rate of
individuals with developmental disabilities in integrated employment, the percentage of
individuals with developmental disabilities in integrated employment, and/or the growth of
integrated employment over time. The term “rate” means the percentage of people in integrated
employment per state population. Their findings showed 13 states as performing well across
these measures (high-performing). Florida was one of the states listed. The results showed
seven common themes in each of the high-performing states. These are listed below:

      Clearly defined goals and data collection
      Strong agency leadership
      Interagency collaboration
      Ongoing training and outreach
      Communication through relationships
      Local control
      Flexibility and respect for innovation

        Financing issues were discussed under the last category. Flexible funding in services
helped to promote supported employment. Some states, such as New Hampshire, reported that a
high level of trust and respect between the state and its providers encouraged innovative problem
solving. The need for flexible funds to help support the employment for individuals was also
noted.


                                                5
        In a follow-up study in 2007, Hall, Butterworth, Winsor, Gilmore, and Metzel completed
a detailed investigation of three of the high-performing states—New Hampshire, Washington,
and Colorado. They found that strategies such as (a) flexibility in funding and practices; (b)
communication of values through data, rewards, and funding incentives; and (c) innovative
diffusion through relationships and training were the most successful elements of a successful
system change effort. Paramount was the expressed solid value base for supported employment.
Below are some of the detailed findings:

      The success in New Hampshire is partially due to operating under minimal state
       regulations.
      Funding in Washington is through block contracts that allow providers the flexibility to
       allocate agency resources based on the changing needs of individuals without having to
       convene formal meetings with case managers to request a change in funding.
      Funding allocations in Washington permitted agencies to support a variety of people in
       integrated employment, including those with more intense needs.
      Local pooling of resources in Colorado allowed the providers to address the varying
       intensity of needs.
      Washington providers believed that block contracts were more effective than
       individualized budgeting.
      Colorado provided upfront funding for services to encourage employment growth.
      At one time in Colorado, providers that enrolled individuals in integrated employment
       received a 25% higher rate of funding from the state than they received for sheltered
       workshop services.
      Recently, Colorado instituted a bonus system of $1,500 to providers for each individual
       whom they supported in a job of his/her choice for 20 hours or more per week, and that
       paid at least minimum wages and lasted for six months. However, the incentive was not
       as effective as upfront funding.

                                Structuring Financing Strategies

        The above references show clearly that well-designed payment methods can serve as an
incentive to the provision of supported employment, while poorly functioning financing
mechanisms contribute to reduced supported employment services. To address this issue,
Revell, West, and Cheng (1999) described different methods used by agencies to fund supported
employment services. Although their comments specifically addressed vocational rehabilitation
services, the principles are also applicable to services funded by developmental disability
agencies. The authors described the steps involved in developing payment mechanisms for
supported employment. The discussion below is taken predominately from their work. To
develop rates, the following steps must be addressed:

   1. Define Services. The full array of activities that are expected to be included in the
      service should be articulated. For example, Phase One services usually include

                                                6
      community-based assessments, job development and placement services, job site training
      and support services necessary to assist the consumer to become stable in employment;
      related skill training and support that is integral to the individual’s employment success;
      and the arrangement of natural supports both on and away from work settings. As
      identified above, the job retention follow-along services are also imperative to successful
      employment outcomes. This service must also be as carefully defined as the Phase One
      services.
   2. Defining Service Units. Service units form the basis for reimbursement. Service units
      are generally based on time, such as hourly or daily units of service, or based on a desired
      service outcome. This method is also called results-based contracting and is discussed in
      more detail below. The determination of the service unit can be critical to the success
      and cost of rendering the services. Small units of service can result in greater
      documentation costs while units such as monthly rates can result in reduced data on
      intensity of service. These needs must be balanced carefully.
   3. Establishing a Service Rate. Rates should be based upon the cost of delivering the
      service. They can be fixed rates or negotiated rates. In a fixed rate system, the funding
      agency establishes a non-negotiable statewide fee level for all vendors of a specific
      service. In a negotiated rate system, the funding agency negotiates the fee rate for the
      specified service with each vendor. Negotiated rates may be based on a specific cost
      formula established by the funding agency or through formal/informal negotiation
      sessions.

        Method of payment also impacts the provision of services. Payment structures can
include fee for services in which the provider receives a certain amount of funds for each unit of
service provided. Another method of reimbursement is contract or slot-based funding, in which
the provider is paid based on participation by the number of individuals with disabilities
receiving a defined service. This payment structure does not track intensity of services provided
to an individual but instead provides funds for a specified number of persons.

         One of the best resources for rate setting is a document developed through the Institute of
Mental Health (Sorensen & Phipps, 1975). Although developed three decades ago and for the
mental health service system, this document is one of the few in print that provides a detailed
approach to rate setting for community-based social services. One of the fundamental premises
of the system is to determine all the costs associated with the provision of services and then
determine the productivity rate that is feasible for the service. Productivity rate refers to the
amount of time that a practitioner will be able to bill for the services. By carefully determining
the productivity rate, the non-billable functions are accounted for. The two biggest errors made
in establishing rates are: (a) failure to account for all the costs, including administrative
activities, expenses, and travel time associated with the service; and (b) assuming that the
practitioner will be able to bill at a high rate of productivity. These cautions are particularly



                                                 7
pertinent to fee-for-service payment structures, but also should be taken into consideration when
setting outcome-focused payments.

        Novak, Mank, Revell, and O’Brien (1999) reviewed the advantages and disadvantages of
results-based approaches to funding supported employment. The authors pointed out that fee-
for-service payment mechanisms may have the unintended consequence of increased billings.
To be able to bill at the increased level, more services than the individual may require may be
provided, which could result in fostering dependence on the service provider rather than
integration and inclusion. It may be in the provider’s best fiscal interest to emphasize billable
hours rather than working toward successful long-term employment of the individual. Results-
based payments have evolved as one way to address this issue and promote outcomes. These
funding designs link provider payments to a pre-defined participant outcome. For example, the
provider may be reimbursed at a set amount of funding when the person with a disability is hired
in a job. These specific outcomes are referred to as benchmarks. The steps required to develop a
results-based payment structure include the following:

      Define the desired service outcome.
      Define the payment points (benchmarks) for each service outcome. Criteria for the
       achievement of the benchmark should be clearly described.
      Establish a fee for each payment point.

        At the time that the above-referenced article was written, Oklahoma, Massachusetts,
Kentucky, and Rhode Island were using this method of payment. The authors discussed how to
insure that funding levels were working for service providers. Several recommendations were
included, some of which are repeated below:

   1. It is critical to balance the funding agencies’ desire to weight pay schedules toward the
      final desired employment outcome and the providers’ need to maintain a steady cash
      flow. Several states have addressed this issue by providing early payments for early
      services, such as assessments and job development.
   2. Payment points should be spaced in such a way that cash flow to the provider is
      reasonably consistent with resource investment.
   3. Proactive strategies should be used to reinforce quality assessments and job planning.
      The better the upfront information, the better chance of success.
   4. The rate structure should accommodate costs associated with serving persons that do not
      eventually receive a job. Paying just for success ignores the reality that some persons
      will not stay employed.
   5. Clear policies must be articulated regarding how the job replacement needs of program
      participants will be handled.
   6. To ensure that providers serve people with significant disabilities, tiered systems should
      be considered to compensate service providers at a higher rate for helping highly
      challenged individuals attain each milestone.

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   7. Another option to address the above issue is to include an add-on time-based
      reimbursement component in the funding mechanisms.

        Although this article discussed Phase One portions of supported employment, it is just as
important to use the same level of diligence when establishing rates for follow-along supports.
Job retention follow-along services appear to be the least defined in the literature. The payment
for these structures must be developed in a manner to ensure that providers receive adequate
payments to provide this service. The comments above on fee-for-service are particularly
important for follow-along services. The full cost of services must be taken into account as well
as the number of hours that are feasible for the practitioner to bill.

             Florida’s Issues Associated with Payments for Supported Employment

        This project entailed detailed interviews with ten states to determine how they have
addressed supportive employment payments and incentives in both vocational rehabilitation
programs and in agencies serving persons with developmental disabilities. The Literature
Review provides a good understanding of the financial issues from a national perspective.
However, to be sure that the interviews with representatives from the ten states address the
particular concerns of Florida, interviews were conducted with Florida agency personnel and
experts in supported employment around the state to identify the issues most prevalent in
Florida. Appendix A includes a list of the professionals that were interviewed. The interviews
were informal and exploratory or used a semi-structured format; and lasted for about 45 minutes
to two hours covering primarily financial issues, payment structures, and coordination of services
between Vocational Rehabilitation and the Agency for Persons with Disabilities.

       The interview findings are summarized below by agency.

Vocational Rehabilitation

        Vocational Rehabilitation has been the primary provider of Phase One supported
employment services since the service was first approved by Vocational Rehabilitation in the
mid-1980s. Supported employment, as well as employment, services are reimbursed through a
results-based benchmark payment structure. The benchmarks for supported employment include
placement, stabilization, transition, and employment outcome. Sixty percent of the payment is
spread across the first three benchmarks at 20% intervals, with the final payment set at 40%.
The total payment equals $7,000 per successful completion. Vocational Rehabilitation will not
embark on Phase One services without a reasonable plan for the provision of Phase Two follow-
along services.

       The persons interviewed did not always have consistent opinions on the issues; however,
in general, most interviewees raised similar concerns regarding the vocational rehabilitation
system. These are summarized below.



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1. Some interviewees believed that the rates were too low. Not all agreed.

2. Almost all persons interviewed stated that the duration of time that providers must render
   services before payment is too long. They stated that there needs to be an upfront
   payment for assessment or some similar activity with another benchmark being
   established. Some stated that this benchmark should result in an increased overall
   payment.

3. Some participants believed that the system of awarding Vocational Rehabilitation
   counselors based upon the number of successful closures is a disincentive to supported
   employment since supported employment services take longer and are more costly than
   employment services.

4. Some interviewees thought that some Vocational Rehabilitation counselors were not
   interested in serving persons with developmental disabilities. Others mentioned that it
   often depends on the counselor and whether he/she is interested in supported
   employment. They reported inconsistency throughout the state.

5. Several interviewees mentioned that the current Vocational Rehabilitation supported
   employment rate structure does not take into consideration the levels of severity and
   advocated for a tiered payment system.

6. Interviewees also mentioned that the payment structure does not acknowledge that some
   individuals will not stabilize on the job and many need additional job placements and
   retraining.

7. There appears to be confusion and inconsistency regarding when and whether Vocational
   Rehabilitation will provide retraining and job placement for persons who have lost their
   job.

8. Many interviewees mentioned that the current payment structure does not address the
   work necessary to engage people in the employment process and to help them explore
   work possibilities.

9. Also, participants stated that the current reimbursements do not address the need for
   people with developmental disabilities to grow in their work and to explore other careers.

10. The interviewees also pointed out that Vocational Rehabilitation counselors have only
    limited amounts of funds, and that employment services are less expensive than
    supported employment. Counselors can serve more people if they limit the use of
    supported employment.

11. Vocational Rehabilitation counselors will not initiate Phase One supported employment
    unless they are convinced that the follow-along services are available. Many counselors

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       assume that this service must be provided through the Home and Community Based
       Waiver and don’t pursue other options, such as natural supports.

   12. There was confusion among the interviewees about when work-related transportation
       could be provided for persons with developmental disabilities.

   13. There is some inconsistency around the state regarding what constitutes appropriate
       completion of benchmarks.

   14. It should be noted that, generally, most interviewees were in support of the benchmark
       payment system. Some recommend an hourly rate supplement for the more severe
       populations.

Agency for Persons with Disabilities

        The Agency for Persons with Disabilities has had a long-term commitment to inclusion
and integrated competitive employment. Recently, they included a goal in the strategic plan to
move 25% of the persons receiving adult day training to supported employment and have been
tracking their progress on this initiative. As noted above, Florida is included as one of the high-
performing states in supported employment.

        For the last several years, Florida has paid for supported employment services on a
quarter-hour basis for group and individual. The rates are geographically adjusted for providers
in Southeast Florida. Rates for adult day training are similarly structured. The Agency for
Persons with Disabilities will fund Phase One services as well as Phase Two services if the
person has been determined ineligible by Vocational Rehabilitation. The Agency is currently
under severe financial pressure and is in the process of making administrative changes to reduce
costs.

        The Agency for Persons with Disabilities provides services on an individualized basis.
For waiver services, providers must enroll as a Medicaid provider and bill Medicaid directly for
the rendered services. Support coordinators are responsible for working with individuals and
their families to develop an individualized support plan. These plans result in a cost plan that
must be prior approved by an independent utilization management company. Providers must
render services in accordance with the Individualized Support Plan and approved cost plan.

        The persons interviewed outlined several issues associated with the Agency for Persons
with Disabilities’ financial system as it pertains to supported employment. As with the
comments on Vocational Rehabilitation, there was not universal agreement on the issues, but
each issue was listed more than once. These comments are summarized below:

   1. The quarterly hour rate structure is costly and inefficient.




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2. The rate is inadequate to cover the cost of follow-along services. The interviewees are
   not sure what cost components were included in the rate.

3. Some believe that the rate is in line with other rates across the country.

4. The personnel productivity factor necessary to break even on follow-along services is too
   high and cannot be met given the travel time requirements and need to document
   services.

5. The type of activities that can be billed is not clear.

6. Providers are able to have sustained revenues when they provide services through adult
   day training. Supported employment revenues are much more difficult to predict.

7. It is very difficult for families and providers to address the need for activities and
   supervision during non-work hours. Families or group home operators have a difficult
   time adjusting to variable work schedules and transportation issues.

8. It is not clear under what circumstances transportation costs will be reimbursed and
   transportation vendors are not readily available in many areas.

9. It is believed by some interviewees that support coordinators do not consistently promote
   supported employment. Some of the interviewees thought that the principles and values
   of supported employment may not be fully understood or embraced by the support
   coordinators. Others thought that the support coordinators would rather deal with more
   consistent and predictable services like adult day training rather than a service that could
   be occasionally problematic (lost job, change of schedule, change of duties, etc.).

10. Authorized hours for follow-along employment supports tend to be approved at 20% of
   the paid hours worked by the individual with a developmental disability. For example, if
   someone works 80 hours, the authorized supported employment hours would be about 16.
   Although likely intended as a guideline, it appears that this level of authorization has
   become a standard. Support coordinators are reportedly reluctant to increase the hours,
   and if they do agree, the timeframe for approval is too long to respond to the need for
   immediate intervention.

11. The 20% guide for the number of hours does not take into consideration the ongoing need
    to retrain. Employers want their staff to be able to do multiple tasks and may need to
    reassign people on a regular basis. The supported employment provider must be able to
    respond to this need, sometimes quickly, to preserve the job.

12. There is inconsistency around the state regarding what agency is responsible for helping
    someone find a new job if needed. The transition back to Vocational Rehabilitation is not
    well defined, and the Agency for Persons with Disabilities has limited funds to provide

                                              12
       retraining and job placement on a regular basis. Providers have been referred back and
       forth between the agencies when they attempt to get Phase One services approved for
       someone who was previously closed in Vocational Rehabilitation.

   13. It is often difficult to get youth transitioning from the schools into supported
       employment. The school system is working locally to try to address this issue through
       cooperative agreements and other methods.

        The issues outlined above are very similar to those documented in the literature as
national concerns. Fortunately, several of the high-performing states and others have developed
multiple solutions. The next stage of this project will focus on how these states have addressed
rate issues, financial incentives, and coordination of services between the vocational
rehabilitation agency and the agency serving persons with developmental disabilities.




                                               13
                                      Review of Ten States

        In order to better understand financing and other related issues, information on ten states
was collected through interviews with representatives from the agencies providing services to
persons with developmental disabilities and Vocational Rehabilitation whenever possible.
Additionally, websites, rate schedules, contract documents, and other available materials were
reviewed. Also, interviews were completed with representatives from ARCs of the selected
states.

        As in Florida, other states are addressing the need to improve and increase the availability
of supported employment services. Prior to the changes to the Home and Community Based
Waiver in 1997, most day programs for persons with developmental disabilities were provided in
day training programs that provided adult living skills training or other training/activity-based
programs. Other options included sheltered workshops. However, with the introduction of
supported employment, it became clear that the technology was available to assist persons with
developmental disabilities to work in integrated environments and receive at least minimum
wage. This change challenged states and providers to approach employment services in a
different manner and to develop the skills to successfully help persons secure and maintain good
jobs in the community. But change presented many challenges to the states, providers, persons
with developmental disabilities, families, and employers.

         While some progressive providers have either converted or expanded their services to
include supported employment, others have found it more comfortable to continue to provide
facility-based programs. Providers also report that there are significant barriers to providing
supported employment, with payment structures being the one that is mentioned most frequently.
Also, some persons with developmental disabilities and their families face significant issues
when supported employment is not designed to address their needs. Quality supported
employment providers are focused on helping persons achieve their personal outcomes and
choices (Sowers, McLean, and Owens, 2002).

        States, providers, persons with developmental disabilities, and their families would like to
see increased opportunities to allow persons to choose employment options and increase this
percentage. As the review of the ten states showed, funding mechanisms can either encourage
these changes or create barriers for all involved.

       The chart below provides an overview of the multiple funding strategies used by
developmental disabilities agencies and Vocational Rehabilitation. Rate payment mechanisms
for developmental disabilities programs will be discussed first.




                                                14
                                        State Payment Mechanisms
State                   Developmental Disabilities        Vocational Rehabilitation
Arizona            Fee-for-service based on state rates       Milestone Payment System
Maryland           Individual rates based on an assessment    Not available
                   and provider rates adjusted by
                   geographical area
Massachusetts      Provider negotiated rates paid by the      Milestone Payment System
                   hour or day
Minnesota          Counties set rates with providers          Milestone Payment System
New Mexico         Negotiated rates through contracts         Two levels of Milestone Payment System
Ohio               Individual rates are set through an        Counties set rates and pay by hour, day,
                   assessment and adjusted by cost of doing   or week
                   business in geographical areas
Oklahoma           Fee-for-service on an hourly basis based   Milestone Payment System
                   upon the number of hours worked by the
                   individual receiving services
Oregon             State established daily or hourly rate     Not available
                   varied by type of provider
Vermont            State contracts with providers who have    Block Contracts
                   flexibility in establishing range of
                   individual services
Washington         Counties negotiate rates with providers    Tiered Milestone Payment System

                                    Developmental Disabilities

       States use multiple payment strategies; in fact, in this review of ten states, no two states
funded services in the same manner. Basically, state developmental disabilities agencies use the
following funding options:

   1. Fee-for-service using a set state rate

   2. Fee-for-service through negotiated contract rates

   3. Individual rates and provider rates combined

   4. Contracts to provide a range of services

Fee-for-Service Payments Using a Set State Rate

        Of the ten states reviewed, Arizona, Oklahoma, and Oregon use fee-for-service rates that
pay for supported employment and center-based employment using a range of unit rates that pay
by the hour of service provision. In Arizona, the rates are set based upon the estimated staff-to-
person ratio, with a cost variances expressed by two geographic areas. The rates are approved by
the support plan team with new or increased cases reviewed through a utilization review system.
To encourage supported employment, the states ensured that the individual supported

                                                 15
employment model paid more than the group model and center-based program. They also pay
for the travel time that the job coach requires to move from site to site. Because the states cap
supported employment through a job coach at 12 months, the states developed a supported
employment aide service to provide the extended services at a reduced cost.

        Oklahoma also pays for services on an hourly fee-for-service basis. However, unlike
Arizona, Oklahoma pays according to the number of hours that the person with developmental
disabilities works rather than by the contact hours that the job coach has with the person working
or other work-related activities. If the person requires job coaching for more than 21% of work
time, they pay a job coach rate times the number of hours that the person works. If the person
requires 20% or less of assistance, the rate drops but the formula remains the same. This
provides the provider with a good estimate of their cash flow and encourages providers to help
the person working increase their hours. The payment mechanism does not provide a tiered rate,
so there could be issues with serving persons that require more on-site assistance. The state also
provides for a one-on-one job coaching service when the person requires extensive supports.
This service is time limited. Persons receiving services are able to move back and forth among
these different services.

       Oregon has a new support service waiver that is based on the principles of self-direction.
Providers are required to set their rates, and consumers choose to purchase these services. Rates
vary by type of provider, including individual employed by service recipient/family, independent
contractor, and provider organization. Facility-based services pay the same per day as group
supported employment, which does not appear as an incentive for group employment. Individual
supported employment pays by the hour. The degree of incentive is dependent upon the number
of hours that would be approved for the person receiving services.

Fee-for-Service through Contracted Rates

        Massachusetts, Minnesota, and Washington negotiate rates with providers and use a
contract to set the rates. Massachusetts negotiates rates with the provider for employment-
related services and pays a ―blended‖ unit rate for all of the employment services. Since
supported employment is often more costly than center-based service, this payment method does
not serve as an incentive to provide integrated employment. In Minnesota, supported
employment is covered under day training. Their counties are responsible for setting the
minimum and maximum rate range that the providers must bill within. These payment methods
do not encourage an increase in supported employment.

        Washington state is known as one of the leaders in providing supported employment.
Their counties have considerable flexibility in how they negotiate with the providers. The state
clearly encourages counties to provide supported employment, and has a state policy that
specifies that work is the first option to be considered for persons with developmental
disabilities, publishing county guidelines that provide a framework for supported employment.


                                                16
Counties pay for supported employment through monthly, hourly, or other negotiated methods,
such as block contracts. Counties also have the option to provide bonuses for performance.

        Although these states are well known for promoting supported employment through
flexible funding strategies, these payment mechanisms do not have much utility for Florida. It is
very unlikely that the state would re-institute provider-based negotiated rates.

        New Mexico’s state policy requires ―Employment First‖ for persons with developmental
disabilities. Rates are negotiated with providers through a performance-based contract. The
contract sets expected performance levels to encourage referrals to Vocational Rehabilitation and
employment placements. Also, the model contracts address incentives that include:

      showcasing successes,

      opportunities to mentor other organizations,

      opportunities for additional training,

      regional and statewide awards, and

      other incentives meaningful to the provider agencies.

Individual Rates and Provider Rates Combined

         Maryland and Ohio use a payment method that combines an individual rate with a
provider rate. In Maryland, the individual rate is determined by a level of need that is set based
upon the results of a needs assessment that takes into account the level of supervision and
medical or behavioral needs. The provider component is a set rate for administrative costs and
the cost of doing business in a geographical area. The two rates are combined into one daily rate
per service. The actual billing of supported employment requires that the person be working for
four hours a day for three days a week. Payment is provided on a daily rate based upon the
number of days that the person works. Having the payment tied to the hours of work rather than
strictly contact hours can be an incentive. However, the requirement for four hours of work per
day may be a barrier for persons who cannot work that many hours per day.

        Ohio sets annual budget limits by service type. There are four levels of need that are
determined by an assessment. These rates are applied across eight different geographic areas to
create 32 different cells. The same rates apply to all day services, which may not serve as an
incentive for supported employment. This method does take into consideration the multiple
levels of need and is uniformly applied through the use of the needs assessment.

Contracts to Provide a Range of Services

       Vermont provides services through contracts with 16 community-based providers. The
contracts give the provider discretion on the range and cost of services for persons receiving

                                                17
services. This mechanism gives the providers flexibility in providing services. Vermont does
not provide any group-based services. All employment services are provided in integrated
settings. Vermont’s focus on individual services and funding flexibility has resulted in an
incentive for supported employment. The state also uses an individual-based incentive, in which
they encourage the individual to convert some of their community support funds to employment
funds. If they convert over 50% of their hours to work, the state will increase their service cap
by $5,000 per year and will annualize that amount. However, the unique nature of the payment
structure and the small number of providers may negatively impact the ability to use these types
of incentives in other areas.

Payment Incentives

        The payment methods described above show that there are numerous payment
mechanisms for services. The flexibility provided for in Vermont and Washington allows the
providers considerable discretion in meeting the individual needs of the persons served.
Vermont’s individual incentives program to increase working hours is a unique approach. When
using fee-for-service programs, the hourly rates paid based upon the number of hours that the
person with developmental disabilities is working provides for incentives to encourage increased
work hours and requires less documentation than payments based on contact hours. When using
unit rates, pricing supported employment so that providers can receive an adequate payment
providing this service, rather than facility-based programs, increased the use of supported
employment. Paying for travel time also is another incentive.

Other Mechanisms Used to Promote Supported Employment

       Vermont and Washington have focused on the use of natural supports to help provide
extended services. These initiatives include encouraging the supervisors and co-workers to
assume some of the duties traditionally completed by the job coaches. To the degree that this
can be successful, it reduces the ongoing financial pressures to fund extended services.

        Several states emphasized the importance of training for providers, consumers, families
and staff. Changing service delivery from a facility-based employment model to an integrated
supported employment program presents numerous challenges for all concerned. Providers need
additional training in how to successfully modify their programs to provide integrated supported
employment. Families and consumers also need additional information regarding work
opportunities, benefit management, and ongoing insurance coverage. Most persons with
developmental disabilities who are working keep the number of hours that they work under 20 to
avoid any issues with benefits and ongoing insurance coverage. There are several ways to
address the issues of ongoing benefits with benefits specialists available throughout the state.
Consumers, families, and support coordinators must be knowledgeable about these alternatives.
One of the greatest concerns is the potential loss of Medicaid benefits. Nationally, 39 states have



                                                18
enacted some form of the Medicaid Buy-In program, which allows former Medicaid recipients to
maintain their Medicaid insurance coverage when they are no longer receiving cash benefits.

                                    Vocational Rehabilitation

        Of the eight states for which information was available, six of those states use the
Milestone Payment System. Two of the states use a tiered milestone to address the costs of
persons who need a higher level of care. Tiered approaches are responsive to the costs
associated with service provision and with the level of need of the consumer. This system
incentivizes the provision of services to people with the most serious disabilities. One concern
expressed about milestone systems is that the system requires the provider to render services for
a considerable period of time before they receive payment and that the systems tend to pay a
higher percentage of the costs at the end of the process. Three of the states provided for
assessments as an upfront payment. However, none of the milestone systems reviewed provided
a significant portion of payment at the front end. Arizona has an optional milestone that
provides for work skill development that could be used to help providers prepare persons for
work and to help explore the work world.

        Ohio and Vermont do not use a Milestone Payment System. In Ohio, providers set their
fees on an hourly, flat fee, or performance basis and must have competitive prices to be
marketable. Consumers choose the provider that best meets their service needs at the best cost.
The Vocational Rehabilitation program in Vermont pays for supported employment through a
block contract. The agency contracts with the 16 developmental disabilities providers. The
funds allow the agencies to hire staff to provide the services. Therefore, rather than a purchase
of service payment structure, the contract results in a staffing model for services. This method
allows the developmental services funds and the Vocational Rehabilitation dollars to be blended
at the provider level and allows maximum flexibility in providing supported employment.

Summary of Vocational Rehabilitation Funding

        It appears that the Milestone Payment System is becoming one of the major methods in
paying for supported employment through Vocational Rehabilitation agencies. These payments
focus on results and may not encourage providers to work with persons with high level of
challenges unless there is a tiered approach. Also, providers complain that they must work with
a person for a considerable time before they receive enough payment to cover their costs. None
of the systems that were reviewed paid a high percentage of the overall rate at the front end of
the process. States want to ensure that the final outcome of stabilized employment is reached.

Comments on Payments and Incentives

       Payment structures provide opportunities to incentivize services through many methods.
Most importantly, the payment should cover the costs and recognize the cost of travel associated
with providing the services. Persons with disabilities should feel comfortable that if they begin

                                               19
to work, they will receive the level of support that is needed to sustain their employment.
Providers must be able to predict costs and revenue in order to provide ongoing services.
Vocational Rehabilitation provides the time-limited services for a significant number of persons
with developmental disabilities. Their ability to attract providers and encourage persons with
developmental disabilities to try employment has a major impact on the developmental
disabilities agencies, such as helping people obtain employment. On the other hand, Vocational
Rehabilitation is dependent on the developmental disabilities agency to have payment
mechanisms that encourage providers to provide extended services.

                                   Interagency Collaborations

        Because supported employment is divided into two phases, with Vocational
Rehabilitation agencies and agencies rendering services to persons with developmental
disabilities providing different components, it is essential that the agencies have an excellent
system of collaboration. Most states have interagency agreements that address this working
relationship. In general, these agreements define eligibility for the different components of
services and articulate the role and function of each of the programs. Vocational Rehabilitation
provides the first phase of time-limited services and the developmental disabilities agency
provides the extended services. States usually require that the developmental disability agency
refer persons to Vocational Rehabilitation for eligibility determination before they provide phase
one services. Vocational Rehabilitation agencies try to ensure that extended services are
available before they initiate supported employment services. This is often a problem, given the
financial constraints that most of the states are functioning under. Although a well-developed
interagency agreement is important, none of the interviewees mentioned the agreement as key to
their success. Instead, when collaboration was working well, it seemed to depend on the ongoing
day-to-day working relationships between the staff in the two agencies. Appendix B includes
copies of interagency agreements from Maryland, New Mexico, and Oregon.




                                               20
                 Transitioning Youth and Young Adults from School to Work

         As in Florida, states throughout the nation are facing the fact that thousands of students
leave high school every year and hope to have a job in the community. Many of these students
expect to work in integrated environments. However, states face funding limitations and waiting
lists for their Home and Community Based Waivers. Vocational Rehabilitation services are
available to youth while they are in school as part of the transitional programs; however, Phase
Two services may not be available because of the limitations in the developmental disabilities
programs. States have used different strategies to address this important issue. Below is a
summary by state of the different approaches used to assist students leave school and enter work.

                          Youth Transitioning from School to Work,
                         Summary of Findings from States Interviewed
Arizona- Vocational Rehabilitation and Developmental Disabilities begin working with the students
while they are still in school. They use day treatment and training programs with integrated employment
as the eventual goal.
Maryland- The state has a Governor’s Transitioning Youth Initiative that has been in place since 1989.
There is a special source of funds to provide services to students with developmental disabilities who are
exiting school for one year after they are 21 years of age or when they exit school. These funds are not
included in the Home and Community Based Waiver.
Massachusetts- This state also has a special appropriation outside of the Home and Community Based
Waiver to provide services to youth exiting from school.
Minnesota- The Vocational Rehabilitation program is able to go into the schools and help students locate
jobs; however, the Developmental Disability agency is often not able to provide the extended
employment services.
New Mexico- Vocational Rehabilitation assigns 10% of their workforce to the schools to assist students
transitioning to work. The Developmental Disability agency has some special funds to help address
extended services.
Ohio- According the interviewee, there is no special program to transition youth from school to work.
Vocational Rehabilitation is available to provide services to youth, but there is a shortage of funds for
extended services.
Oklahoma- The state provides two state-funded services for persons on the waiting list—supported
employment and workshop services. Vocational Rehabilitation works with the schools to provide Phase
One services.
Oregon- Information was not available.
Vermont- Supported employment staff begin working with students while they are still in school and
usually find them a job prior to graduation. Between Vocational Rehabilitation and resources from the
Home and Community Based Waiver, funding is available for most young adults transitioning from
school.
Washington- The state legislature provides special state funding for youth coming out of school. All
students are transitioned to the work environment. The Vocational Rehabilitation counselors start
working with youth while they are still in school.




                                                    21
        As the above information shows, many states are beginning to address the needs of youth
and young adults transitioning from school by ensuring that vocational rehabilitation is provided
in the schools to help the youth and young adults find out about the world of work and secure
employment before they leave school. However, since most students will need some type of
follow-along services, the long waiting lists for Waiver services in many states pose challenges.
Several states have addressed this through special, time-limited funding for extended services.




                                               22
                                         Issues and Options

        The literature review and interviews with stakeholders and with the ten states revealed
several issues that interfere with successful implementation of supported employment. These are
briefly summarized below:

          Vocational Rehabilitation                                 Developmental Disabilities
 Need for upfront payment or assessment                    Need to modify the quarter-hour rate structure
                                                           Extended services do not give provider sustained
 Need to provide incentives for VR Counselors
                                                           income
                                                           Support Coordinators may not always encourage
 Rate structure should recognize levels of severity
                                                           supported employment
 Opportunities for professional growth are needed          Transportation is a problem
 Need to use more natural supports for extended
                                                           Non-work-hour supervision must be addressed
 services
 Need to clarify flow between time-limited and             Extended employment may not be available for
 extended services                                         transitioning students

       Each one of these issues and possible solutions is discussed below.

                                      Vocational Rehabilitation

Need for Upfront Payment or Assessment

       Issue.

        Florida’s Vocational Rehabilitation program has four milestones to pay for supported
employment. Assessment is not paid as a separate milestone but is expected to be provided as
part of the placement process. The payment system pays 20% for the first milestone of
placement, 20% for each of the next two milestones, and 40% for the last one. Providers have
expressed the need for an additional payment or a higher percentage of the payment to be paid up
front. The fact that assessment is not a separate service is seen by some stakeholders as a
problem. The assessment is an essential component of the supported employment process and, if
done properly, helps to ensure that the person with developmental disabilities has an opportunity
to explore the work world and choose a job that is of interest to them and allows the use of their
skills. When the assessment is not a specific service, it may not get the needed attention. Also,
providers may not have the upfront funds necessary to spend a great deal of time on this step.

       Option.

        In the eight states that were available for review, six used the milestone system. One
state, Arizona, provides work skill development as an optional service. In 2007, Mank reported
that method of assessment is now called discovery and has emerged to better determine
individual talents and preferences. Adding an additional vocational rehabilitation service of

                                                      23
assessment or discovery would permit the provider to spend more time with the consumer and
help ensure that the job placement is a good job match, and allows the person with
developmental disabilities to express their unique abilities.

Need to Provide Incentives for Vocational Rehabilitation Counselors

       Issue.

       In Florida, the Vocational Rehabilitation Counselors can receive bonuses for productivity
measured by the number and quality of job placement. Also, Vocational Rehabilitation
Counselors work within a specific budget, and employment services are much less expensive
than supported employment services. Due to these constraints, Vocational Rehabilitation
Counselors are likely to be more inclined to provide employment services than the more
expensive supported employment services.

       Option.

       Even with these disincentives, Vocational Rehabilitation Counselors continue to provide
supported employment services. It would be much more appropriate if these counselors were
rewarded for this work. Vocational Rehabilitation has a ―Leader Board‖ that sets the goals for
which counselors can receive bonuses. Changes to this ―Leader Board‖ could be made to ensure
that Vocational Rehabilitation Counselors who successfully provide supported employment
services are eligible for bonuses for this work.

The Rate Structure Should Be Designed to Recognize Levels of Severity

       Issue.

         The literature on results-based supported employment emphasizes that this system could
result in providers only rendering services to persons who can easily be placed in a job situation.
The additional costs of working with persons with greater needs are not covered through the
milestone system.

       Option.

        Some systems vary their rates by the level of support needed by the consumer. This
payment structure is called a tiered system. A tiered system allows the providers to receive
payments at higher rates for serving individuals that will require more intensive support services.
Tiered systems are one method to reduce the potential for results-based payment methods to
emphasize the easier-to-serve, less costly individuals. Oklahoma’s milestone system is an
example of the counterbalancing effect of a tiered payment system. Oklahoma reported that
services to persons with more functional limitations remained constant when the state moved
from a fee-for-service system to the milestone system. Another state reviewed, New Mexico,
uses a tiered system to address the complex needs of persons in the Jackson class members.

                                                24
Using a tiered system could address the issue raised by stakeholders that the current payment
system does not provide enough funds to cover the cost of the job placement for persons with
behavioral and functional complexities.

Opportunities for Professional Growth Are Needed

       Issue.

        Persons with developmental disabilities have the same needs to grow professionally and
have the option to change their jobs as other employees. However, these options may be limited
for persons with developmental disabilities. Once a person finds a job, they are often not
considered for additional job placement and may be expected to remain in the job indefinitely.

       Options.

       Several of the states included in the review described a very fluid system between the
Vocational Rehabilitation and developmental disabilities programs. Persons can move from
extended services back to time-limited Phase One when the person needs additional job
placement services. This fluidity of services enables persons with developmental disabilities to
receive re-training and professional growth.

Need to Use More Natural Supports for Extended Services

       Issue.

        Some of the stakeholders stated that there should be more of an effort to encourage
natural supports in the work environment for extended services. Vocational Rehabilitation will
not initiate Phase One services unless they are assured that extended services are available. With
the limited funding of the Home and Community Based Waiver, this can lead to serious
reductions in opportunities for work.

       Option.

        The use of natural supports can extend the available funding, allowing more people to
receive services. Washington, Maryland, and Vermont have concentrated on this resource. In
Washington, the state has worked with some of the major companies to establish ongoing natural
supports within the companies. The University of Vermont offers technical assistance in the use
of natural supports in the work environment.

Need to Clarify Flow between Time-limited and Extended Services

       Issue.

       Several of the stakeholders reported that there is an inconsistency in the state regarding
when a person who was successfully closed by Vocational Rehabilitation can again receive job


                                                25
placement services. In some parts of the state, services will be started again; in other, re-training
services are not provided. The state does not have a clear policy in this area.

       Option.

       As stated above, several of the states allow an easy flow between Vocational
Rehabilitation and Developmental Disabilities. Vermont services are the best example of this.
They use blended funding to achieve a seamless system. This option is probably not viable for
Florida, but a clear policy that addresses re-entry into the Vocational Rehabilitation system
would help ensure that services are better integrated and consistently implemented. Washington
has purchased extensive training for their providers to increase the use of natural supports in the
work settings.

                                    Developmental Disabilities

Need to Modify the Quarter-Hour Payment Structure

       Issue.

       The quarter hour payment structure is expensive for providers due to extensive
documentation and does not provide incentives for supported employment services. Providers
and other stakeholders state that the reimbursement rate is not adequate to cover extended
services. Also, the one rate for individual supported employment does not adequately address
the needs of persons with extensive needs. Although not a policy, extended services tend to be
approved at 20% of hours worked by the person with disabilities. This is adequate for some
people, but does not address the needs of persons with more functional limitations.

       Option.

        States such as Ohio and Maryland have a tiered payment structure for supported
employment services that is based upon the level of need. The payment is directly tied to the
level of need, which is determined through an assessment process. Ohio has four categories of
level of need. They also recognize the cost of doing business in different parts of the state. This
tiered payment system recognizes that the cost of providing extended services varies based upon
the support needs of the individual. Because payment is based upon an assessment, the level of
payment is predictable for the provider and the state.

Extended Services Do Not Give Providers Sustained Income

       Issue.

        The literature on supported employment and the interviews revealed that providers are
better able to sustain reimbursements and predict revenues when providing center-based services.
Therefore, although providers may be very interested in providing extended supported
employment services, they find that they cannot do so and meet their financial obligations.

                                                 26
       Option.

        Oklahoma and Maryland have developed a payment method that addresses this issue.
Both states pay for extended services based upon the number of hours that the person with
developmental disabilities works rather than contact hours. Therefore, if a person works 30
hours a week, the monthly payment is the rate times 30 hours. The provider has flexibility in
how often they contact the individual or complete other supported employment activities. The
extended services are reimbursed if the person remains successfully employed. Oklahoma also
has an hourly-based service that is provided if the person needs one-to-one supports. This
payment method, however, could result in only the persons requiring the least amount direct
service receiving services. To counter this shortcoming, the tiered system described above could
be used to determine the level of need and provide a higher hourly rate for those persons with
higher needs for support. Also, the stakeholders raised the issue of travel time between work
sites. The rate setting for this type of payment structure should take into consideration the travel
time and also should be set to ensure that the providers can be reimbursed for their costs and in a
manner that will ensure that integrated supported employment pays at least as well as center-
based services.

Support Coordinators May Not Always Encourage Supported Employment

       Issue.

        According to the stakeholder interviews, there was a perception that support coordinators
may be reluctant to encourage supported employment because they are concerned about possible
loss of benefits, and that supported employment can result in more complications such as varying
schedules and potential job loss. It may be easier to work with center-based services. Also, they
may not feel knowledgeable about supported employment and the associated actions necessary to
maintain benefits.

       Option.

        Support coordinators may need additional training regarding the advantages of integrated
employment, how to use income disregards such as the Plans for Achieving Self-Support
(PASS), and in learning what resources are available to help them with employment issues. The
Area Offices have employment benefit coordinators who can help the support coordinators with
employment issues. There are also benefit specialists available throughout the state to help
persons with disabilities develop strategies to work and keep their benefits. Also, there should
be a clear definition of what services are provided by the employment coordinators and benefit
specialists. The employment coordinators could possibly provide some of the training.

Transportation Is a Problem

       Issue.


                                                 27
       The stakeholders and the literature cite transportation as a major barrier to supported
employment services. At times, providers and persons with developmental disabilities have not
been clear whether transportation to and from services is a covered service.

       Option.

       All the states that were interviewed indicated that transportation to and from work is a
covered service. However, states acknowledge that locating transportation providers can be a
problem. Some states have agreed to pay family members and friends to provide the
transportation at the state travel reimbursement rate.

Non-work Hour Supports Must Be Addressed

       Issue.

        During the interviews both in Florida and in the ten states, the issue of non-work hour
supports was mentioned. Centered-based services were originally designed to provide a safe and
supervised setting for persons with developmental disabilities. The choice of integrated
employment can pose problems for families or residential programs. Centered-based services
offer a regular schedule from 8 to 5 in a known environment. Persons who are ready to try
integrated employment may not be able to pursue jobs that require variable work hours or night
shifts. Additionally, at this time, most persons with developmental disabilities work about 20
hours per week and have several other hours available during the week. Families may not be
able to provide the necessary support during non-work hours, and residential programs may not
have adequate staffing during hours when persons routinely were in center-based services.

       Option.

        States have addressed this issue by providing community-based support services.
Vermont provides one-on-one support services to enable the person with developmental
disabilities to volunteer and enjoy community services and other community-based services.
Florida may be eliminating the nonresidential support services that could have been used to
address this need. The service, Companion, is an option but, perhaps, the rate should be
modified to address the variable level of needs of the individuals.

Extended Employment May Not Be Available for Transitioning Students

       Issue.

        In Florida, as well as the rest of the nation, students are graduating from high school with
the hopes of entering the work environment. Vocational Rehabilitation services are available to
the students while they are still in school. However, Vocational Rehabilitation will not provide
time-limited Phase One supported employment unless they are assured that extended services
will be available. This poses serious problems, since Home and Community-Based Services are

                                                 28
limited by appropriations and there may not be funds necessary to provide extended services.
Arranging supported employment is one option to address this issue, but may not be feasible for
many persons with developmental disabilities. Without extended employment services, most
persons with developmental disabilities will not be able to work in integrated settings.

       Option.

        Several of the states reviewed have established special appropriations to address this
issue. These appropriations are outside of the Home and Community-Based Services, with some
available for a set period of time after graduation. Many persons with developmental disabilities
could graduate from school with a job if the state had a special appropriation to address the need
for extended services. Some states offer only supported employment or other work services for
persons when they graduate.




                                               29
                                        Recommendations

         Based upon the issues and options listed above, a set of recommendations are listed
below:

1. Vocational Rehabilitation should consider adding an assessment (discovery) service to ensure
   that upfront job discovery and exposure to work environments is adequately addressed.

2. Vocational Rehabilitation should consider modifying the ―Leader Board‖ to add rewards and
   bonuses for successful provision of supported employment services.

3. Vocational Rehabilitation should consider developing a tiered payment system to
   acknowledge the varying levels of needs of persons receiving Phase One supported
   employment services.

4. Vocational Rehabilitation and the Agency for Persons with Disabilities should consider
   developing policy that addresses the need for persons to change jobs and to be re-trained by
   Vocational Rehabilitation. This should be included in their interagency agreement and
   implemented uniformly throughout the state.

5. Vocational Rehabilitation and the Agency for Persons with Disabilities should expand their
   use of natural supports through the provision of training to providers, families, and persons
   with developmental disabilities on ways to develop and use natural supports in the work
   setting.

6. Vocational Rehabilitation and the Agency for Persons with Disabilities should provide clear
   direction to the field regarding the availability of Vocational Rehabilitation after someone
   has been successfully closed. This should be included in the interagency agreement.

7. To improve integration of services, the Agency for Persons with Disabilities should consider
   adopting a tiered milestone payment system for the provision of Phase One supported
   employment services. Although the Agency is not the first payer for Phase One services,
   they do provide services for those persons not approved by Vocational Rehabilitation for
   supported employment services.

8. The Agency for Persons with Disabilities should consider eliminating the quarter-hour
   payment system for supported employment and consider adopting a tiered supported
   employment payment system for extended services.

9. The Agency for Persons with Disabilities should develop a means to pay for extended
   services based upon the number of hours that the person with developmental disabilities
   works rather than on contact hours.

10. The Agency for Persons with Disabilities should consider using a comprehensive assessment
    to determine the level of support needed for employment and tie the results of that

                                                30
   assessment to the individual cost guidelines. The assessment should reflect the level of
   assistance needed based on functional, medical, or behavioral issues. The rate structure
   should be tiered to reflect the complexity of the needs.

11. The Agency for Persons with Disabilities should consider developing a mandatory training
    program for support coordinators that addresses supported employment, benefit and income
    disregards, and other employment issues. The Agency should also consider developing a
    recognition program for support coordinators that successfully help persons with disabilities
    achieve integrated employment.

12. The Agency for Persons with Disabilities should ensure that all parties realize that
    transportation to and from work is a covered service and should develop transportation
    options that address the need for transportation in rural areas and for hours that address
    variable work schedules.

13. The Agency for Persons with Disabilities should develop models that demonstrate how
    supports for non-work hours could be provided using existing services in the Home and
    Community Based Waiver. Companion services are possible alternatives. Unfortunately, the
    Agency is planning to eliminate non-residential support services. Perhaps that service could
    be reinstated for persons working in integrated supported employment.

14. The Agency for Persons with Disabilities should consider requesting a special appropriation
    to provide integrated supported employment for students transitioning from school who have
    completed Vocational Rehabilitation time-limited services and will be able to transition to
    integrated work.

15. The rate payment for extended services should be reviewed. The rates should reflect the cost
    of providing extended services, including the travel time necessary to cover multiple sites,
    and be established using a tiered approach.

             Recommendations Regarding Phase-In of Changes and Safeguards

        The phase-in of these changes should be planned by Vocational Rehabilitation and the
Agency for Persons with Disabilities to ensure coordination and a smooth transition. One of the
first changes should be modification of the Vocational Rehabilitation milestone system to a
tiered system. Currently, Vocational Rehabilitation is examining the payment structure and
should ensure that setting rates for tiered payments is included in that work. The Agency for
Persons with Disabilities should establish a similar tiered payment system for Phase One for
those individuals not eligible for Vocational Rehabilitation Services. This payment structure
should be as similar to the Vocational Rehabilitation payment method as possible under the
Home and Community Based Waiver. The tiered system should be based upon a valid and
reliable assessment to determine the level of need for the different tiers.



                                                 31
       The states that use the tiered payment system have only two tiers. We recommended that
Florida do the same. The costs necessary to make these changes should be calculated, and both
Vocational Rehabilitation and the Agency for Persons with Developmental Disabilities should
consider including them in their Legislative Budget Requests.

        The modification of the payment rate for extended services should be coordinated with
Medicaid to ensure that this payment structure can be used in the Florida Home and Community
Based Waiver. The amount of needed support should be determined by a valid and reliable
instrument, and the results should be used as part of the individual cost guideline process.
Because this payment is based upon results—the number of hours that the person works, and not
contact hours per se—the rate structure must be reviewed and new rates established. This should
be completed as soon as possible to incentivize the providers’ ability to render this service.
These changes may increase the cost of supported employment services, and the Agency for
Persons with Disabilities should calculate the increased cost and consider requesting additional
dollars to cover the service. Since this method of payment presents a major change for the
agency, a pilot should be considered before full implementation.

        The interagency agreement between the two agencies should be modified to address the
movement of persons receiving services from one agency to the other. Many states have a very
flexible arrangement that allows persons to receive additional Vocational Rehabilitation services
when they wish to change careers or need a new job. The agreement should reflect the reality
that persons with developmental disabilities want to have the same opportunities for career
growth and change as do the rest of the work force.

        Both agencies should coordinate the policy changes and training programs that should be
put in place. Vocational Rehabilitation should first look at the ―Leader Board‖ framework, and
include bonuses or incentives for helping persons with developmental disabilities receive
supported employment. Both agencies should provide additional training to the Vocational
Rehabilitation counselors and the support coordinators providing services to persons with
developmental disabilities on:

      Planning for employment, including benefit counseling, and addressing non-work hours.

      The advantages of work for the person receiving services.

      How to develop natural supports in the workplace.

      Coordination between Vocational Rehabilitation and the Agency for Persons with
       Disabilities regarding the provision of services and the ability of persons to move back
       and forth between agencies.

      Roles of the support coordinator, the job coach, the employment specialist, and the
       benefit counselor.

                                               32
       After the training and expectations have been made clear, the Agency for Persons with
Disabilities should develop a recognition program for support coordinators who have assisted
persons with developmental disabilities into an integrated working environment, especially for
those who helped persons achieve 30 or more work hours a week.

                                            Safeguards

        Some persons with developmental disabilities require supervision during most of the day.
Careful planning must be done to ensure that they have meaningful activities throughout the day.
Families have major concerns about non-work hour activities. Although individual companions
or services are helpful, people also enjoy being with others during the day. When planning for
the expansion of supported employment, the agencies must address this issue. A community
support service should be available to assist the person participate in community recreational
programs, volunteer work, and other activities that provide meaning and structure to the day.

        The cost of system changes should be calculated and addressed. Some increased cost
may be offset by savings in adult day training programs. However, if persons receive the amount
of support necessary, and the cost of providing extended services is covered, the immediate cost
of supported employment may not be significantly less expensive than day services. Once the
new rate is set, it will be important to calculate the cost differential and share that with decision
makers. Although the immediate cost of supported employment may be considered relatively
high, the long-term costs will likely be less, given that some people will develop natural supports
or need less assistance over the years. These projections should be included in the calculations,
if possible.

                                      Additional Follow-up

        The Florida Developmental Disabilities Council, Vocational Rehabilitation, and the
Agency for Persons with Disabilities should be commended for their promotion of employment
for persons with developmental disabilities. The Council should ask to be informed regarding
any rate setting actions taken by Vocational Rehabilitation and the Agency for Persons with
Developmental Disabilities. The Council should also work with both agencies to promote
meaningful and productive activities and supports for non-work hours. If not already involved,
the Council should work with other stakeholders to support the Medicaid Buy-In for continued
Medicaid coverage after persons are employed.




                                                 33
                                          References

Cimera, R. E. (1998). Are individuals with severe mental retardation and multiple disabilities
      cost-efficient to serve via supported employment programs? Mental Retardation, 36 (4),
      280-292.

Hall, A. C., Butterworth, J., Gilmore, D. S., & Metzel, D. (2003). High-performing states in
       integrated employment. Research to Practice, 9 (1), 1-4.

Hall, A. C., Butterworth, J., Winsor, J., Gilmore, D., & Metzel, D. (2007). Pushing the
       employment agenda: Case study research of high performing states in integrated
       employment. Intellectual and Developmental Disabilities, 45 (3), 182-198.

Mank, D. M. (2007). Employment. In S. L. Odom, R. H. Horner, M. E. Snell, & J. Blacher
      (Eds.), Handbook of developmental disabilities (pp. 390-409). New York: Gilford Press.

Mank, D. M., Cioffi, A., & Yovanoff, P. (2003). Supported employment outcomes across a
      decade: Is there evidence of improvement in the quality of implementation? Mental
      Retardation, 41 (3), 188-197.

Metzel, D. S., Boeltzig, H., Butterworth, J., Sulewski, J. S., & Gilmore, D. S. (2007). Achieving
       community membership through community rehabilitation provider services: Are we
       there yet? Mental Retardation, 45 (3), 149-160.

Novak, J., Mank, D. M., Revell, G., & O’Brien, D (1999). Paying for success: Results-based
      approaches to funding supported employment. In G. Revell, K. J. Inge, D. M. Mank, &
      P. Wehman (Eds.), The impact of supported employment for people with significant
      disabilities: Preliminary findings of the National Supported Employment Consortium
      (pp. 25-42). Richmond, VA: Virginia Commonwealth University Rehabilitation
      Research and Training Center on Workplace Supports.

Novak, J., Rogan, P., Mank, D. M., & DiLeo, D. (2003). Supported employment and systems
      change: Findings from a national survey of state vocational rehabilitation agencies.
      Journal of Vocational Rehabilitation, 19, 157-166.

O’Day, B. (1999). Policy barriers for people with disabilities who want to work. American
      Rehabilitation, 25 (1), 8-15.

Office of Disability Employment Policy (2002). Independence through employment – New
       Freedom Initiative 2002. Washington, DC: United States Department of Labor.

Revell, G., Kregel, J., Wehman, P., & Bond, G. R. (2000). Cost effectiveness of supported
        employment programs: What we need to do to improve outcomes. Journal of
        Vocational Rehabilitation, 14, 173-178.


                                               34
Revell, G., West, M., & Cheng, Y. (1999). Funding supported employment: Are there better
        ways? Journal of Disability Policy Studies, 9 (1), 60-79.

Sorensen, J. E., & Phipps, D. W. (1975). Cost-finding and rate-setting for community mental
       health centers. Rockville, MD: National Institute of Mental Health.

Sowers, J. A., McLean, D., & Owens, C. (2002). Self-directed employment for people with
      developmental disabilities: Issues, characteristics, and illustrations. Journal of Disability
      Policy Studies, 13 (2), 97-104.

Sulewski, J. S., Gilmore, D. S., & Foley, S. M. (2006). Medicaid and employment of people
      with disabilities – Findings from the National Survey of State Systems and Employment
      for People with Disabilities. Journal of Disability Policy Studies, 17 (3), 158-165.

Wehman, P. (2006). Integrated employment: If not now, when? If not us, who? Research and
     Practice for Persons with Severe Disabilities, 31 (2), 122-126.

Wehman, P., & Kregel, J. (1995). At the crossroads: Supported employment a decade later.
     Journal of the Association for Persons with Severe Handicaps, 20 (4), 286-299.

Wehman, P., Revell, W. G., & Brooke, V. (2003). Competitive employment: Has it become the
     ―first choice‖ yet? Journal of Disability Policy Studies, 14, 163-173.

West, M., Hill, J. W., Revell, G., Smith, G., Kregel, J., & Campbell, L. (2002). Medicaid HCBS
      waivers and supported employment pre- and post-Balanced Budget Act of 1997. Mental
      Retardation 40 (2), 142-147.

West, M., Johnson, A., Cone, A., Hernandez, A., & Revell, G. (1998). Extended employment
      support: Analysis of implementation and funding issues. Education and Training in
      Mental Retardation and Developmental Disabilities, 33 (4), 357-366.

West, M., Revell, G., Kregel, J., & Bricout, J. (1999). The Medicaid Home and Community-
      Based Waiver and supported employment. American Journal on Mental Retardation,
      104 (1), 78-87.

West, M., Wehman, P., & Revell, G. (2002). Extended services in supported employment:
      What are providers doing? Are customers satisfied? In D. Dean, P. Wehman, & J.
      Kredel (Eds.), Achievements and challenges in employment services for people with
      significant disabilities: A longitudinal impact of workplace supports (pp. 85-98).
      Richmond, VA: Virginia Commonwealth University Rehabilitation Research and
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Winsor, J. E., Hall, A. C., Butterworth, J., & Gilmore, D. S. (2006). Pushing the integrated
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      Performing States, 15, 1-8.

                                                35
                                    Individuals Interviewed

Mark Barry – ARC of Nature Coast

J. B. Black – Agency for Persons with Disabilities

Kathy Burton - Department of Education (brief discussion and emails)

Mike Capps

John Hall – ARC of Florida

Nancy Hanisch – Agency for Persons with Disabilities

Pam Hinterlong – Vocational Rehabilitation

Debra Linton – ARC of Florida

Dave Mank – University of Indiana

             Group Interview with Florida Association of Rehabilitation Facilities

At the Tallahassee office interviewees included:

Sheree Keeler – Employment Consultant

Suzanne Sewell – Director of Membership and Program Services

Courtney Swilley – Member Service Specialist

Ellyon Turnquest – Member Services Specialist

                          Individuals Who Participated by Telephone

Sarah Alloway                                        Don Corwin
ARC of Martin County, Inc.                           MacDonald Training Center
2001 S. Kanner Highway                               5420 W. Cypress
Stuart, FL 34994                                     Tampa, FL 33607
Phone: (772) 283-2525                                Phone: (813) 870-1300

Michelle Bellamy                                     Cheryl Elder
Quest, Inc.                                          Key Training Center
P.O. Box 531125                                      130 Heights Avenue
Orlando, FL 32853                                    Inverness, FL 34452-4571
Phone: (407) 218-4300                                Phone: (352) 795-5541



                                               36
Karen Higgins                             David Lin
PARC                                      Palm Beach Habilitation Center
3190 Tyrone Boulevard North               4522 South Congress Avenue
St. Petersburg, FL 33710                  Lake Worth, FL 33461
Phone: (727) 345-9111                     Phone: (561) 965-8500

Pamela Jenkins                            Jean-Marie Moore
LARC, Inc.                                Goodwill Industries Suncoast, Inc.
2570 Hanson Street                        P.O. Box 14456,
Fort Myers, FL 33901                      St. Petersburg, FL 33733-4456
Phone: (239) 334-6285                     Phone: (727) 523-1512

Carlos Jimenez                            Jerry Motter
Quest, Inc.                               ARC Broward/BARC Housing, Inc.
P.O. Box 531125                           10250 N.W. 53rd Street
Orlando, FL 32853                         Sunrise, FL 33351
Phone: (407) 218-4300                     Phone: (954) 746-9400

Kelly Johanassen                          Maureen Nowatarski
UCP of East Central Florida (WORC)        PARC
1100 Jimmy Ann Drive                      3190 Tyrone Boulevard North
Daytona Beach, FL 32117                   St. Petersburg, FL 33710
Phone: (386) 274-6474                     Phone: (727) 345-9111

Pete Karlan                               Tina Phillips
ARC of Martin County, Inc.                Palm Beach Habilitation Center
2001 S. Kanner Highway                    4522 South Congress Avenue
Stuart, FL 34994                          Lake Worth, FL 33461
Phone: (772) 283-2525                     Phone: (561) 965-8500




                                     37
         Appendix A

Ten States Interview Summaries
              Supported Employment Payment Structure and Incentives - Arizona

              Division of Developmental Disabilities, Department of Economic Security

        Arizona operates their program for developmental disabilities through an 1115 Waiver
rather than the Home and Community Based 1915 C Waiver used by the other states. The state
operates five different day programs including:

         Day treatment and training

         Day treatment and training to transition young adults into the work world

         Center-based employment (workshops)

         Group-based supported employment (enclaves and work crews)

         Individual supported employment

         Providers must enroll through Medicaid and meet the credentialing requirements for the
specific service. They bill the Division of Development Disabilities directly on a unit rate basis.
Center-based and day treatment services are funded on a set hourly rate, while supported
employment services are billed based upon a rate that reflects the staff-to-consumer ratio. The
individual services team works with the family and provider to determine the rates. A utilization
review system is in place for new services or for increased services. For both the facility-based
services and supported employment, the state has set a high and low rate according to the
geographical area where the services are provided. The higher rate is for the more remote areas
that serve a smaller population of individuals with developmental disabilities. In setting the
rates, the state tried to incentivize supported employment by setting the individual rate higher
than the group rate and by paying for the travel time for the job coach to get to the different work
sites. Transportation to and from work is also a covered service, and family or friends can be
reimbursed at the state mileage rate to provide the transportation.

        The state has ten rates for group supported employment and two rates for individual
supported employment. Also, the state has established a new service, employment aide, to
provide for ongoing supervision when job coaching is no longer needed. The state has
established a 12-month limit on job coaching and uses the aide position to provide ongoing
extended supervision.

          Below is a chart showing the range of payment for each of the services by low and high
levels:




                                                A-2
    Arizona Department of Economic Security, Division of Developmental Disabilities
                              SFY 08 Adopted Rates
                           Employment Support Services
 Description                                          Density Unit of Service Rate
 Center-Based Employment
 Center-Based Employment                                             High        Client Hour          $5.51
 Center-Based Employment                                             Low         Client Hour          $6.06

 Employment Support Aide - Center-Based Employment                   High        Client Hour          $16.04
 Employment Support Aide - Center-Based Employment                   Low         Client Hour          $17.64

 Group Supported Employment
 Staff : Consumer Ratio Of 1:2 To 1:2.5                              High        Client Hour          $18.28
 Staff : Consumer Ratio Of 1:2 To 1:2.5                              Low         Client Hour          $20.98

 Staff : Consumer Ratio Of 1:2.51 To 1:3.5                           High        Client Hour          $12.19
 Staff : Consumer Ratio Of 1:2.51 To 1:3.5                           Low         Client Hour          $13.99

 Staff : Consumer Ratio Of 1:3.51 To 1:4.5                           High        Client Hour          $8.87
 Staff : Consumer Ratio Of 1:3.51 To 1:4.5                           Low         Client Hour          $10.20

 Staff : Consumer Ratio Of 1:4.51 To 1:5.5                           High        Client Hour          $7.09
 Staff : Consumer Ratio Of 1:4.51 To 1:5.5                           Low         Client Hour          $8.16

 Staff : Consumer Ratio Of 1:5.51 To 1:6.5                           High        Client Hour          $5.91
 Staff : Consumer Ratio Of 1:5.51 To 1:6.5                           Low         Client Hour          $6.80

 Employment Support Aide - Group Supported Employment                High        Client Hour          $18.23
 Employment Support Aide - Group Supported Employment                Low         Client Hour          $20.05

 Individual Supported Employment
 Individual Supported Employment                                     High        Staff Hour           $28.04
 Individual Supported Employment                                     Low         Staff Hour           $30.85

 Employment Support Aide - Individual Supported Employment High                  Client Hour          $18.24
 Employment Support Aide - Individual Supported Employment Low                   Client Hour          $20.06
   (Arizona Department of Economic Security, Division of Developmental Disabilities Rate book, 2007, p. 33)

        While center-based services are provided on an hourly basis requiring direct contact with
the person receiving services, job coaches are paid for a broader range of services. A job
coach/job search hour includes activities such as:


                                                    A-3
      Meetings with the consumer and/or employer

      Travel time of staff to and from the consumer’s worksite

      Other tasks necessary to support the consumer to keep or obtain the job and be successful
       including, but not limited to, job development, career development, counseling, on-the-
       job training, job coaching, ongoing employer contact, job search activities, mobility
       training, worksite analysis, and report writing.

        Also, the state is using performance-based contracting to try and encourage the center-
based employment programs to move toward supported employment. Performance measures are
collected on areas such as productivity of the employee with developmental disability, hours
worked, number referred to Vocational Rehabilitation, etc. These requirements are new and
have been initiated to track progress toward supported employment and integrated work. The
state considers enclaves and work crews to be integrated employment opportunities.

        The state is attempting to move to more integrated supported employment and has a goal
to obtain a 25% rate of integrated employment for people enrolled in day programs by the end of
this calendar year. As of May, they were at 18.12%.

        The state has set up training opportunities for the providers to encourage them to commit
more resources to supported employment and begin to convert their sheltered workshops to
integrated employment; but, to date, interest has not been at the desired level. Employment
specialists are also in place in the regions to help the support coordinators access employment
services.

        The Division for Developmental Disabilities has a close working relationship with the
Rehabilitation Services Administration (RSA) and refers all persons with developmental
disabilities who wish to work to Vocational Rehabilitation for the time-limited supported
employment services. It is estimated that over half of the referrals are served by the
Administration.

        To help youth transition from school to work, the RSA and the Division for
Developmental Disabilities have worked with the school systems, parents, and teachers to
develop options for youth. The day treatment and training program is one option to help the
youth gradually move from a school-based program to work. The emphasis is on eventual
integrated work environments. Because of the 1115 Waiver, the state is not able to have a
waiting list for Medicaid services and, therefore, must find a way to provide some level of
service to the youth graduating from school. Vocational Rehabilitation services usually start at
age 16 to 18. Most students stay in school through their 22nd birthday.




                                              A-4
        The provider issues tend to be about the rates (which they say are too low), the new
performance measures, the fact that the state does not provide for travel time for the employment
aides, and new quality management requirements.

        According to the representative from the ARC of Arizona, individual integrated
employment is a real challenge. The change in the minimum wage recently legislated in Arizona
has resulted in a reduction of work hours for some individuals. The families and persons with
developmental disabilities are not unified in their opinions regarding work. Some would prefer
integrated employment while others are more comfortable with a sheltered workshop or day
training.

                             Rehabilitation Services Administration

        The RSA is responsible for providing vocational rehabilitation services and supported
employment. The Vocational Rehabilitation State Plan states that the organization is responsible
for providing the time-limited supported employment while the Division of Developmental
Disabilities is responsible for extended employment. The array of supported employment
services follows the traditional group of services. RSA will not initiate a case unless they are
assured that the extended services are available. There are no limitations to the number of times
that a person can receive supported employment from the Administration.

      Services have been provided through contracts procured through a bidding process.
However, the state is now moving to a Milestone system. The milestones for supported
employment are described below:

      Work skills development milestone (optional)

      Job preparation

      Job placement - milestone

      Job support retention - four weeks

      Job support retention - eight weeks

      Job stabilization

      Successful rehabilitation

       The Scope of Work document includes a section on Contract Incentives that reads as
follows:

       A 10% incentive payment (.10 X amount paid to the Contractor for successfully
       closed cases in the contract year) will be paid upon achieving all five (5) incentive
       standards as follows:

                                              A-5
       1. The counselor satisfaction rating is above average, based on RSA data.

       2. The contractor is a minimum of 20% above the state’s average of clients who
          are accepted by the Contractor and proceed through the Job Placement
          Milestone based on RSA data.

       3. The RSA District’s average client wage at closure is 10% higher than the
          District’s average wages at closure for VR clients.

       4. The average client work week at closure is thirty (30) hours or more, based on
          RSA data.

       5. The percentage of clients closed who receive employer paid health care
          benefits exceed the statewide average from the previous state fiscal year, and
          shall not be below 10% of the successfully rehabilitated closed cases based on
          RSA data.

       The state does have a special program for high school transitioning but, unfortunately,
does not have any special funding sources. For those with the most severe disabilities, the
Division of Developmental Disabilities organization addresses their needs. For those that are
―higher functioning‖ youth, the RSA assumes the lead.

        According to the interviewee, families express concern about supervision when their
adult child requires 24-hour supervision. The biggest issue is to ensure that long-term extended
supported employment is available.

        The ARC of Arizona stated that community-based integrated employment is a big
challenge. The new minimum wage requirements have resulted in the loss of hours for some
people with developmental disabilities. Families are not unified in what they would like to see
for their adult children. Some families prefer sheltered workshops, enclaves, and work crews
while other families strongly prefer integrated work environments. The providers have
considerable control of what services the consumer is offered and accepts. Many providers
appear to remain more interested in providing group supported employment and services. The
financial information presented above seems to verify this impression.

                                            Sources

1. Interview with Bertha Villegas-Kinney from the RSA

2. Interview with Linda Flores from the Division for Developmental Disabilities

3. Arizona Department of Economic Security Division of Developmental Disabilities. (2003).
   Methodology and assumptions DES/DDD published rate schedule. Retrieved September 5,
   2007, from:
   http://www.de.state.az.us/ddd/downloads/vender/Methodology%20and%20assumptions.pdf

                                              A-6
4. Arizona Department of Economic Security Division of Developmental Disabilities. (2007).
   Rate book. Retrieved September 1, 2007, from:
   http://www.de.state.az.us/ddd/downloads/vender/rates/ratebook_20070701.pdf

5. Arizona Department of Economic Security. (2006). Scope of work: Employment services.
   Retrieved August 31, 2007, from: http://www.de.state.az.us/RSA/pdf/rfi/amendedscope.pdf




                                           A-7
          Supported Employment Payment Structures and Initiatives - Maryland

                  Maryland Developmental Disabilities Administration (DDA)

        Maryland Department of Disabilities funds services for persons with developmental
disabilities through two Home and Community Based Waivers—Community Pathways and New
Directions. Community Pathways is the main waiver for persons with developmental disabilities
and serves about 9,000 people. New Directions is a much smaller waiver based on the principles
of self-direction and will enroll about 100 persons per year. The Department also operates a
state-funded program that includes persons with disabilities other than developmental
disabilities, such as traumatic brain injury and other disabilities that result in functional
limitations. The Department serves a total of 23,000 persons.

         The state currently has 16,000 persons with developmental disabilities on their waiting
list for waiver services. Seven years ago, there was a concentrated effort to reduce that waiting
list, which was successful. However, over the last two to three years, the waiting list has grown
to this new high. The waiting list consists of persons of all ages.

        DDA provides family and individual supports, which are low-level supports, such as
budgeting, medication administration, job coaching, transportation, respite care, behavioral
supports, developing relationships, environmental modifications, and adaptive equipment. They
also provide community supported living arrangements and residential or individual family care.

        The day and supported employments are rate-based services. The rates are comprised of
two components, individual and provider. The individual component is determined by a level of
need assessment that takes into account the level of supervision that is required and the medical
and behavioral special needs. They are currently using their own assessment instrument, known
as the Individual Indicator Rating Scale. The state is researching other instruments to use to
determine the level of need. The provider component contains a set rate for administrative costs
plus an adjustment for the cost of doing business in different geographical areas of the state. The
two rates are calculated and combined into one daily rate per service. The services included
under day services are:

      supported employment
      adult pre-vocational
      day habilitation

       The calculation results in the same daily rate regardless of which service is provided. For
example, after the rates are combined and calculated, the state will pay the same daily rate for
supported employment as for day habilitation. This is a recent change. Previously, supported
employment was at a lower rate. A few years ago, DDA instituted a one year Fiscal Incentive
Program for Employment services, which offered providers a one-time incentive payment, based
on 10% of the individual component of the rate, for individuals that were successfully employed

                                               A-8
in the community for six months. Unfortunately, due to regulatory requirements and other
issues, the program started out slowly and was not able to meet its expectations. It was not
continued. According to the person interviewed, the program might have been successful if
more time had been available.

        To bill for day services, the person must be in attendance at the program. Billing for
supported employment is dependent upon the amount of time the person is working. The person
must work for at least four hours per day for three days a week to bill supported employment. It
is not dependent upon the amount of contact time required to provide the services. This payment
structure may set up unintended preference in favor of serving persons with lower levels of need
because they require a smaller investment of staff contact time. It also presents difficulties when
trying to move someone onto a job in a gradual fashion. For example, if someone works for four
hours a day for four days a week, the provider can bill the daily rate times the number of days
(four). If the person does not require much supervision, this service would be less expensive
than providing a center-based program; however, if they require significant supervision, the
service payment may not cover the cost. Below are two examples of rates by geographical area:

       Region 2 Washington D. C. Metro
                              Supervision/Assistance Level
                              1             2            3            4             5
                     1      $11.22        $14.22       $20.07       $26.09        $37.97
         Health/
                     2      $12.83        $15.83       $21.69       $27.70        $39.58
         Medical
                     3      $15.43        $18.43       $24.28       $30.30        $42.18
          Level
                     4      $18.94        $21.94       $27.79       $33.81        $45.69
                     5      $22.03        $25.02       $30.87       $36.90        $48.77

       Region 3 Rural Areas
                                  Supervision/Assistance Level
                              1             2            3            4             5
                     1      $12.11        $15.34       $21.65       $28.15        $40.97
         Health/
                     2      $13.84        $17.08       $23.40       $29.89        $42.70
         Medical
                     3      $16.65        $19.88       $26.20       $32.69        $45.51
          Level
                     4      $20.43        $23.67       $29.98       $36.48        $49.29
                     5      $23.77        $26.99       $33.31       $39.81        $52.62

        Plans of care are approved at the regional level and submitted to the state level, where
they are generally accepted.

       Vocational Rehabilitation and DDA have a very good cooperative working relationship
in Maryland. However, the waiver regulations do not permit providers to bill for Vocational
Rehabilitation services on the same day as they bill DDA waiver services, which, according to
the providers, is a barrier to providing supported employment. Providers also report that the

                                               A-9
rates established by DDA do not cover the costs of the upfront work associated with helping
someone find and train for a job. The providers also are hesitant to bill Vocational
Rehabilitation due to the amount of paperwork they say is involved. DDA has routinely been
providing the first phase of supported employment for many people with developmental
disabilities. Now, state policy requires the persons who are served by DDA and want to work
first must be referred to Vocational Rehabilitation Services before DDA will provide them with
supported employment.

        The state has a Governor’s Transitioning Youth Initiative that has been in place since
1989 and provides a special source of funds to service students with developmental disabilities
who are exiting school for one year after their 21st birthday or when they exited school. These
funds are appropriated by the legislature outside of the waiver funds to provide for a year of
transition. Last year, Maryland provided services to 500 students through this initiative. These
funds pay for supported employment. According to the interviewee, families of youth exiting
schools want to have integrated competitive employment. The average cost for supported
employment services per year is $15,000; however, the cost for youth graduating is much higher,
especially for those with autism.

       According to the interviewee, about 3,500 of the 9,000 served on the Community
Pathways Waiver are working. It should be noted that the state counts enclaves as a working
environment if the service is paid for by a business and the enclave interacts directly with that
business. Also, the state is promoting the use of natural supports to help provide extended
services. About 25% of the providers are doing a good job in setting up environments to be self-
supporting.

       According to the ARC of Maryland, the families are in favor of supported employment in
independent inclusive settings. The state has a good reputation for providing supported
employment to those individuals who can work fairly easily in general business environments.
They now are having more difficulty serving persons with severe and profound disabilities. As
with many groups nationally, Maryland families report that one challenge is the lack of
supervision for persons with developmental disabilities when they are not working. The state
encourages volunteer work and does permit the person to move from day habilitation to
supported employment on a weekly basis if necessary. The ARC believes that the supported
business approach holds promise for people with very challenging behaviors, but did not have
any information on payment rates and how it is financially supported.

                 Division of Rehabilitation Services, Department of Education

        Unfortunately, the representative from Vocational Rehabilitation was not available for
interviews during the August time period. The State Plan for Rehabilitation Services was
reviewed and showed an emphasis on supported employment. The Cooperative Agreement
between the Division of Rehabilitation Services and DDA was also reviewed. It showed


                                             A - 10
Rehabilitation Services being responsible for the time-limited front-end services and DDA being
responsible for extended services. The report showed that the Division of Rehabilitation
Services spent $880,481 in Fiscal Year 2006 while the DDA spent $50,676,455.

                                            Sources

1. Community Pathways and New Direction Waivers: www.dhmh.state.md.us/ddda.waiver.htm

2. Cooperative Agreement on Employment Services between Maryland State Department of
   Education, Division of Rehabilitation Services and Maryland State Department of Health and
   Mental Hygiene, Developmental Disabilities Administration, December 2006, Expanded
   Agreement.

3. Interview with Christine Marchand, ARC of Maryland

4. Interview with Colleen Gauruder, Maryland Department of Health and Mental Hygiene,
   Developmental Disabilities Administration.

5. State Plan for Division of Rehabilitation Services Attachment 7.3

6. State Regulations 10.22.17 at www.dsd.state.md.us/comar/10/10.22.17




                                            A - 11
              Supported Employment and Payment Incentives - Massachusetts

                                Department of Mental Retardation

        The Department operates a Home and Community Based Waiver that includes an array
of community-based services including work/day supports that are defined as ―routine provision
of supports and services provided in accordance with an individual that are designed to support
the individual in paid employment, to foster vocational skills to assist in the movement toward
paid employment, to support retirement activities, or to assist the individual to gain the social
and leisure skills for increased presence and independence in the community.‖ The state also
provides individual supports for intermittent or ongoing services to improve community
membership, which are not work oriented. The employment services include assessment, job
development, job placement, and long-term supports. They also include enclave and work
crews. The state also provides sheltered workshops and center-based day services.

         Services are purchased through contracts with providers in the community on a unit rate
basis. The providers develop and negotiate their rates using the rate setting directions provided
by the State Purchase of Service Manual. The unit rate for the community-based day services
and employment support services are either hours or days, but day rates are most common.
According to the interviewee, the providers are permitted to ―blend‖ the rates across services,
which results in supported employment and day services ―blended‖ into one rate. The provider
bills the Department of Mental Retardation on a monthly basis for each individual. The blended
rate is described in the State Purchase of Service Manual as ―This blending of the unit rates into
one rate for one program can occur in any one of several situations, e.g., consumers in a single
location with costs varying according to their individual service needs may lead to a ―blended‖
rate for the program as a whole…‖ This payment mechanism may not encourage the provision
of individual supported employment services. Of the 5,600 persons served under the
employment contracts, 1,500 are reportedly in an individual inclusive job while another 1,400
are in group job placements. The state is currently considering ―breaking out‖ supported
employment services from the blended rates to create an emphasis on supported employment.

         It should be noted that the state has a Medicaid State Plan service for day habilitation that
is not included in the waiver. Although no longer allowed by the Center for Medicare and
Medicaid Services, to date, Massachusetts has been ―grandfathered‖ in to continue the service.
These programs are typical day habilitation center-based programs and currently serve about
5,000 placements.

        The collaboration with Vocational Rehabilitation is dependent upon the working
interactions at the local level. There is not a formal working agreement to address how
Vocational Rehabilitation should provide Phase One, and the Department of Mental Retardation
the extended services.



                                               A - 12
         For children transitioning out of school, the state has established a special initiative under
legislative Chapter 688 with special appropriation for the youth. The youth tend to go to a mix
of settings.

        The state monitors the contracts by the area offices and has a statewide data system that
collects information on a per person basis. The information is now shared throughout the
system.

       The interviewee stated that the state still has a reliance on center-based group programs.
The key question is how the supervision will be provided when the individual is not working.
Families have mixed perspectives on services. Some younger and more progressive families are
very supportive of individual inclusive employment. However, other families still prefer the
group environment because of its predictability.

                              Massachusetts Rehabilitation Commission

       The contact person for supported employment was unavailable for an interview.
However, the Vocational Rehabilitation payment system has been described in the literature.
Novak, Mank, Revell, and O’Brien (1999) showed that Massachusetts uses a results-based
milestone system similar to that in Oklahoma, but with fixed rates for each milestone instead of a
percentage of the total cost. Below is a description of that system.

Services or Service                 Service Units or Payment             Fee Per Service Unit or
Outcomes                            Points                               Payment Point
Assessment                          Benchmark 1:   Plan for assessment               $520
                                    Benchmark 2:   Assessment Report                 $780
Placement                           Benchmark 1:   Career Plan                      $1,400
                                    Benchmark 2:   Placement                        $1,400
                                    Benchmark 3:   30-day retention                  $700
Initial employment supports         Benchmark 1:   30-day retention                 $1,480
                                    Benchmark 2:   Stabilization                    $2,220
Additional support (or substitute
                                         Time increment: Hour                Variable hourly rate
for other service components)

                                               Sources

1. Margaret Van Gelder- Department of Mental Retardation

2. Massachusetts Department of Mental Retardation, (2007). Purchase of Service Manual.
   Boston, MA: Massachusetts Department of Mental Retardation.

3. 115 CMR 7.00



                                                A - 13
4. Novak, J., Mank, D., Revell, G., & O’Brien, D. (1999). Paying for success: Results-based
   approaches to funding supported employment. In G. Revell, K. J. Inge, D. Mank, &
   P.Wehman (Eds.), The impact of supported employment for people with significant
   disabilities: Preliminary findings from the national supported employment consortium (pp,
   25-42). Retrieved September 3, 2007, from Virginia Commonwealth University
   Rehabilitation, Research, and Training Center on Workplace Supports and Job Retention
   website: http://www.worksupport.com/research/viewContent.cfm/111




                                           A - 14
          Supported Employment Payment Structures and Incentives - Minnesota

             Minnesota Department of Human Services Disability Services Division

        The Developmental Disability (DD) program operates a Home and Community Based
Waiver to provide supports for persons with developmental disabilities. The waiver provides
day training and supported employment services. There are two day programs provided called
day training and habilitation. The supported employment is provided through the day training.
The services are mostly facility-based. About 13,000 people get full or partial day services.

       The counties are responsible for setting the minimum and maximum rate range that the
providers must bill within. The counties must submit their recommended rates to the
Commissioner on an annual basis.

       They have not seen much growth in supported employment in the last few years. The
payment issues have been a problem. There is no incentive to provide supported employment.
Rates are set through negotiations at an individual level and a provider level. The services are
managed at the county level. Some counties have formal contract management and monitor the
providers while others do not have as many resources.

        Vocational Rehabilitation is the first payer for Phase One of supported employment.
Unfortunately, Vocational Rehabilitation is getting more restrictive in its referrals. The
interviewee was not sure that persons are getting referred to services. Counties are complaining
that Vocational Rehabilitation is not providing Phase One.

       For youth transitioning out of school, Vocational Rehabilitation staff are going into the
schools to help students locate jobs; however, DD may not be able to provide the extended
services. Some of the youth do not want to work.

      The state is working on a new payment structure that will address day training, supported
employment, structured day, and adult day care (retirement type of service).

       Providers are concerned about rates. Families would like more consumer-directed
services. Many want integrated supported employment.

    Rehabilitation Services Branch, Department of Employment and Economic Development

        It was not possible to interview the person representing the Rehabilitation Services
Branch. However, information is available on their website. In January 2006, the Rehabilitation
Services Branch implemented a performance-based system for job placement services funded by
the Vocational Rehabilitation Program and is applicable to supported employment services. The
system provides for time-limited supports, which means an independent, integrated, single-site
job in the community with ongoing employment support services after the Vocational
Rehabilitation funding ends.

                                              A - 15
       The system pays for the completion of milestones through a fixed payment at each of the
four supported employment milestone events under a single authorization of $2,900.

      Placement Plan - $300

      Job Hire - $900

      Job Stabilization - $700

      Job Retention - $1,000

The document did not indicate any tiered approach to address persons with additional needs.

                                            Sources

1. Interview with Deb Schauffert- Department of Human Services Disability Services Division

2. Minnesota Department of Employment and Economic Development. (n.d.). Performance-
   based service delivery system. Retrieved September 3, 2007, from:
   http://www.deed.state.mn.us/rehab/performance_based

3. Section 252.46, Minnesota Statutes 2006.




                                              A - 16
         Supported Employment Payment Structure and Incentives – New Mexico

                   Department of Health Developmental Disabilities Support

        The contact person for Developmental Disabilities Support was not available for an
interview during this segment of the project. However, their website is an excellent source of
information regarding their services. The Developmental Disabilities Support section provides
services to children and adults with developmental disabilities through both general funds and
the Developmental Disabilities Waiver. The 2007 Strategic Plan reports that New Mexico ranks
above the national average with 36% of working-age adults receiving day services being
employed at least part time. The Strategic Plan identified employment of people with
developmental disabilities as a key strategy for the following years.

      The Developmental Disabilities Waiver Service Standards (April 2007) establish an
Employment First principle that reads as follows:

       When planning services for adults, work is the priority outcome of supports and
       services, individuals with developmental disabilities will be offered employment
       as a priority service over all other day service options. Individual placements are
       the preferred service. All Supported Employment services are required to
       demonstrate appropriately high expectations, enriched opportunities for learning,
       skill building and use of least restrictive environments. Supported Employment
       services shall be provided at the times and places as required by the individual’s
       employment up to 365 days a year.

Under the waiver, the state has four models that address the Employment First principle. They
are listed below:

   1. Self-Employment: Through a process of discovery, an individual may elect to start his or
      her own business. The provider agency, along with the team, provides the necessary
      assistance to develop a simple business plan, conduct a market analysis of the product or
      service, and help establish necessary tax ID, incorporation documents, bookkeeping
      records, and adherence to local and state codes. Self-employment does not preclude
      employment in the other models.
   2. Individual Supported Employment: Employment with supports in integrated settings.
   3. Group Supported Employment: More than one individual works in an integrated setting
      with staff supports on the site. Regular and daily contact with non-disabled coworkers
      and/or the public occurs; and
   4. Intensive Supported Employment: Offers one-to-one job coaching for employed
      individuals in integrated community-based settings. Intensive supported employment is
      intended for individuals who need 1:1 job support (face-to-face) 32 or more hours a
      week.


                                             A - 17
        Annual performance contracts establish the negotiated rates with providers and specify
the target performance on key measures. Two of the measures address employment, measuring
the number of individuals referred to the Division of Vocational Rehabilitation and the number
of individuals currently not employed who will move into Supported Employment services.
Rates were not shown in the standards or the contract. Also, the contracts address incentives,
which are listed below:

      showcasing successes,
      opportunities to mentor other organizations,
      opportunities for additional training,
      regional and statewide awards, and
      other incentives meaningful to specific provider agencies.

       In addition to the waiver services, the state has two employment services that are funded
by the General Fund as special projects. These include traditional supported employment that is
available to persons with developmental disabilities who are 22 years of age and older and
seeking employment. The person must be interested working for at least ten hours per week at
minimum wage.

        The second service is called the Model Employment project and is designed to promote
awareness and skills of stakeholders involved in the development of meaningful employment for
individuals with significant challenges. This is a site-based program that is staffed to provide
assistance for this population. As part of this model, support providers in collaboration with the
interdisciplinary team develop work for the self-advocate employees, matching individual
interests, and providing opportunities for learning and skill development. Job coaches are
available at the sites to provide training and assistance to therapists, self-advocates,
parents/guardians, and staff of case management, community provider, and/or supported
employment agencies on an ongoing basis.

        The ARC of New Mexico is primarily an advocacy organization for persons with
developmental disabilities. Those people with developmental disabilities that have found
sustained employment are supporters of the employment focus. Others have found it frustrating
because they do not believe that the job coaches are listening to the wishes of the customer.
Those with more severe disabilities are not able to find jobs and are going into workshops. Other
families and people with disabilities are feeling pressured to work in integrated environments
when they prefer a workshop setting. One of the main issues is that there are not enough
resources to help people find jobs that they will enjoy.

        New Mexico appears to be addressing the employment needs of persons with
developmental disabilities in multiple ways. This state will be further analyzed in the next phase
of the project.



                                              A - 18
                 Department of Education Division of Vocational Rehabilitation

       Vocational Rehabilitation in New Mexico works with the Department of Health to
provide a supported employment program for persons with disabilities. The services provided
include job exploration, counseling, job development, job placement, and job coaching. They
also have flexible funds that can purchase services such as transportation assistance, clothing,
and other services or items needed for employment.

        Vocational Rehabilitation has adopted the Milestone results-based payment system for
supported employment services. The state is under a lawsuit known as the Jackson lawsuit that
impacts services provided by both Vocational Rehabilitation and Developmental Disabilities
Supports. For the Vocational Rehabilitation system, the lawsuit requires a separate payment
structure for services. Vocational Rehabilitation operates under an agreement with
Developmental Disabilities Supports to provide the time-limited supported employment services.
Vocational Rehabilitation will not initiate the time-limited services unless they are assured that
extended services will be available from Developmental Disabilities Supports. According to the
interviewee, the flow between Vocational Rehabilitation and Developmental Disabilities
Supports can be a problem due to limited Developmental Disabilities resources.

      The method of payment is displayed below by the non-Jackson and Jackson lawsuit
payment schedules.

     Jackson Class Members
                   Milestones                                      Rates
      1 – Assessment                                                $500
      2 – Placement                                                $1,500
      3 – Job retention (4 weeks)                                  $1,500
      4 – Job retention (10 weeks)                                 $1,500
      5 – 90 days stabilization                                    $1,800

     Non-Jackson Class Members
                   Milestones                                      Rates
      1 – Assessment                                                $500
      2 – Placement                                                 $700
      3 – Job retention (4 weeks)                                   $700
      4 – Job retention (10 weeks)                                  $700
      5 – 90 days stabilization                                    $1,200

       The state is addressing the issue of transitioning youth by assigning about 10% of the
Vocational Rehabilitation counselors to the schools to help youth prepare for transition. They


                                              A - 19
are also trying to find grants to help fund the project. Additionally, the Department of Health
does have some funds in place to help transition youth.

      According to the interviewee, Vocational Rehabilitation will re-open cases after closure.
The key question is ―why should it not be opened?‖

       Comments from the providers tend to be mixed. Many like the results-based payment
model while others say that it is not enough money and complain about cash flow issues.
Vocational Rehabilitation has about 600 providers.

                                             Sources

1. New Mexico Department of Health. Building a Healthy New Mexico. (n.d.). Retrieved
   September 4, 2007, from the website: http://www.health.state.nm.us/partners.html

2. New Mexico Department of Health, Developmental Disabilities Support Division. (2007).
   Developmental disabilities waiver service standards. Retrieved September 5, 2007, from:
   http://www.health.state.nm.us/ddsd/regulationsandstandards/documents/DDW_Standardf.pdf

3. New Mexico Department of Health, Developmental Disabilities Support Division. (2007).
   Annual performance contract for community access and adult habilitation services..
   Retrieved September 5, 2007, from:
   http://www.health.state.nm.us/ddsd/providerinformation/CommunityAccessContract.htm

4. Interview with Debbie Hambel- Division of Vocational Rehabilitation

5. Interview with Rebecca Shuman- ARC of New Mexico




                                              A - 20
             Supported Employment Payment Structures and Incentives - Ohio

        Ohio was listed by Hall et. al in 2003 as one of the high-performing states in integrated
employment. Their state interagency collaboration has been a strong feature for over ten years.
The Vocational Rehabilitation and Mental Retardation/Developmental Disabilities agencies have
had formalized collaborative efforts and have worked to try and streamline their payment
structures. Both agencies share a mutual goal of achieving employment for persons with
developmental disabilities. The results of the interviews are listed below.

            Ohio Department of Mental Retardation and Developmental Disabilities

        An interview was conducted with a representative from the Department of Mental
Retardation and Developmental Disabilities (MR/DD) who is knowledgeable about their
supported employment program. Supported employment is one of four services included in the
new array of adult services. The array includes supported employment enclave, community
employment, vocational habilitation, and adult day support. The vocation habilitation service is
sheltered employment in workshops, and the adult day support program is more geared to
retirement and leisure. The state has two Home and Community Based Waivers known as
Waiver 1 and the Individual Option Waiver. Supported employment is included in both waivers.
The service components under supported employment include the following:

      assistance to start a business,
      enclaves,
      job development,
      job training, and
      ongoing support.

        Rates are set using a combination of an acuity scale and a cost of living factor known as
the ―cost of doing business.‖ The acuity scale is used to determine the level of need for all
services, with the exception of residential and transportation that are managed separately. The
acuity scale results in the assignment of the person with a developmental disability to a level of
need labeled A, A-, B, or C. The levels of need are reflected by the staff-to-person ratio required
to provide a specific service. Budget limitations for all needed services are established by the
level of need score. The calculation is complicated and the interviewee referred to Rule 5123:2-
9-19 entitled HCBS waivers - payment standards for adult day support, vocational habilitation,
supported employment enclave, supported employment community, and non-medical
transportation. The section on setting the rates reads as follows:

       The budget limitations for adult day support, vocational habilitation, supported
       employment-enclave, and/or supported employment-community services, as
       reflected in appendix B to this rule, have been determined by use of a projected
       service utilization of two hundred forty days per year multiplied by 6.25 hours of


                                              A - 21
        attendance each day multiplied by four fifteen-minute units per hour to obtain the
        maximum based of six thousand fifteen-minute units of service that may be
        received per person per twelve-month waiver eligibility span. The six thousand
        units are then multiplied by the rate for adult day support/vocational habilitation
        services that correspond to the group to which each individual would be assigned
        based on completion of the ODMRDD acuity assessment instrument. The rate
        selected when calculating an individual’s budget limitation is further determined
        by the cost of doing business factor that applies to the county in which the
        individual is anticipated to receive the preponderance of these services. The
        budget limitation is calculated on a per-person basis and is applicable to the
        twelve-month waiver eligibility span for each eligible individual.

        The rates that were developed using the above methodology are listed below from the
rule.

        The following are annual budget limitations that apply to adult day support, vocational
habilitation, supported employment-enclave, and supported employment-community services
when these services are provided separately or in combination. Annual budget limitations are
arrayed by cost of doing business (CODB) category numbered 1 through 8.

               CODB            Group A        Group A-1       Group B         Group C
             Category 1         $9,480           $9,480        $17,040         $28,380
             Category 2         $9,540           $9,540        $17,220         $28,680
             Category 3         $9,660           $9,660        $17,400         $28,980
             Category 4         $9,780           $9,780        $17,580         $29,280
             Category 5         $9,840           $9,840        $17,760         $29,580
             Category 6         $9,960           $9,960        $17,940         $29,880
             Category 7         $10,080         $10,080        $18,120         $30,120
             Category 8         $10,140         $10,140        $18,240         $30,420

        The rates vary significantly by category levels and by level of acuity. As shown above,
there is a significant difference across categories and groups. However, the payments for each
level of adult day services appear to be paid at the same level. This does not seem to serve as an
incentive for supported employment. This is supported by the low percentage of supported
employment as compared to the billing rates of all four adult day services.

        The state is renewing its efforts to promote supported employment. According to the
person being interviewed, there is a longstanding interagency agreement to address supported
employment between Vocational Rehabilitation and MR/DD, but there is a serious problem in
the availability of extended services.




                                              A - 22
        The person being interviewed said there really was no special program for transitioning
youth. They went on to say that the providers complain about the amount of documentation
needed to justify the levels of acuity staff-to-person ratios. The families state that if the person is
not served on the waiver, then no services are available. There is a waiting list for waiver
services that is maintained by the counties.

        According to the person interviewed from the Ohio ARC, the opportunities for supported
employment are limited and dependent upon the county. Sheltered workshops are the primary
day service that most people with developmental disabilities receive. ARC would like to see a
greater emphasis on supported employment and better coordination between Vocational
Rehabilitation and Developmental Disabilities.

                                     Vocational Rehabilitation

       Vocational Rehabilitation (VR) services are provided through the Ohio Rehabilitation
Services Commission. The service array for supported employment includes community-based
assessment, vocational evaluation, personal adjustment, work adjustment, job coaching, and job
placement. The state VR office does not set fees. The fees are set by the individual providers
through a bid process that is open to any qualified vendor. These fees are reviewed by counties
and are posted on the website. The VR office data agrees with the MR/DD office that the
amount of supported employment provided in the state is below the desired level.

         The Ohio VR office posts its fees and fee schedules on their website:
http://www.rsc.ohio.gov/vendor/Introservices_text_only.asp. The Community Service Manual
states that:

       While the RSC does not set or control fees, staff seek to obtain quality services at
       reasonable cost. RSC staff purchasing services are expected to follow applicable
       agency policies including least cost consumer choice and comparable benefits. If
       a consumer chooses to receive services from a qualified service provider other
       than the least-cost provider, RSC will only pay for the services in the amount it
       would cost for the consumer to go to the least-cost service provider….

Therefore, it appears that the state regulates fees by using the lowest bid for service provision.
The manual also states that providers may establish their fees using three different methods that
are list below.

   1. Hourly fees- These fees are charged for actual time spent in billable services in
      increments of 15 minutes, and for a total amount of time no smaller than 15 minutes.
      Hourly fees are authorized and billed on a monthly basis.
   2. Performance-based fees- This payment structure is used for job placement. These fees
      are authorized separately prior to the start of each service and are billed separately
      according to the achievement of specific and substantive benchmarks. The providers

                                                A - 23
      describe these benchmarks in their fee schedules and service descriptions. Often, the
      providers us a three-tiered structure that includes: (a) intake, (b) job development and
      placement, and (c) retention. If intake is used as a benchmark, it must include a
      placement plan. Once a benchmark is completed, authorization for the next benchmark
      should be requested and authorized.
   3. Flat fees- These fees are authorized at one time for the full service without incremental
      benchmarks. The service description should clearly state what is provided and what
      determines the end of the service. Billing/payment occurs after the full service has been
      provided.

        The manual goes on to describe a mix of hybrid fee structures that create potential for
billing disputes. The providers cannot mix or blend hourly performance-based and flat fee
structures for a single service.

        Below is a chart composed of an example of services and providers to get a sense of the
rates offered in Ohio, from the 2007 schedule of fees.

Service Provider                     Service                                      Fee
Cuyahoga County Board of MRDD        Community-based assessment                   $100.00 per day
                                     Work adjustment                              $100.00 per day
                                     Job coaching                                 $45.00 per hour
                                     Job placement: Performance-based
                                        Job seeking skills training               $700.00 per person
                                        Job placement                             $750.00 per person
                                        Job retention                             $800.00 per person
                                     Job placement: Hourly
                                        Job seeking skills training               $45.00 per hour
                                        Job development                           $45.00 per hour
                                        Job retention                             $45.00 per hour
Lorain County Board of MRDD          Community-based assessment
                                        8 – 20 hours per week                     $865.00 per week
                                        21 – 30 hours per week                    $1,240.00 per week
                                        31 – 40 hours per week                    $1,615.00 per week
                                     Vocational evaluation
                                        Vocational evaluation                     $800.00 per week
                                        Vocational testing (individual battery)   $80.00 per hour
                                        Career profile/exploration                $80.00 per hour
                                     Personal adjustment                          $58.00 per hour
                                     Work adjustment
                                        8 – 20 hours per week                     $865.00 per week
                                        21 – 30 hours per week                    $1,240.00 per week
                                        31 – 40 hours per week                    $1,615.00 per week
                                     Job coaching                                 $58.00 per hour

                                               A - 24
                                          Job placement
                                             Job placement package                        $2,573.00 flat rate
                                             Job seeking skills training                  $645.00 flat rate
                                             Placement                                    $645.00 flat rate
                                             Closure                                      $1,283.00 flat rate
                                          Benefits consultation                           $80.00 per hour
                                          Transportation                                  $12.50 one way
(The Ohio Rehabilitation Services Commission website: http://www.rsc.ohio.gov/vendor/Introservices_text_only.asp)

                                                   Sources

1. Ohio Department of Mental Retardation and Developmental Disabilities. (n.d.). Information
   for County Boards. Retrieved September 3, 2007, from:
   http://www.mrdd.ohio.gov/counties/odmrdd.htm

2. Rule 5123:2-9-19, Ohio Administrative Code.

3. Interview with Don Bashaw from the Ohio ARC

4. Interview with Leslie Paul from the Ohio Department of Mental Retardation and
   Developmental Disabilities

5. Interview with Pamela Schneider from the Ohio Rehabilitation Services Commission

6. Ohio Association for Persons in Supported Employment. (n.d.). Ohio APSE News,
   newsletter of the Ohio APSE: The network on employment. Retrieved September 3, 2007,
   from: http://www.apse.org/documents/OH_Fall_2006.pdf

7. Ohio Rehabilitation Services Commission. (n.d.). Community rehabilitation program (CRP)
   manual. Retrieved September 3, 2007, from:
   http://www.rsc.ohio.gov/vendor/CRP_Manual_web.pdf

8. Ohio Rehabilitation Services Commission. (n.d.). Find a service provider – text only from
   http://www.rsc.ohio.gov/vendor/Introservices_text_only.asp




                                                    A - 25
          Supported Employment Payment Structures and Incentives - Oklahoma

          Developmental Disabilities Service Division, Department of Human Services

        Supported employment services are included in the Home and Community Based
Waivers that are available in Oklahoma. As with most states, waiver employment services
provided by the Developmental Disabilities Service Division (DDSD) are only available for
persons who are not eligible for services from the Department of Rehabilitation Services that
provides vocational rehabilitation. When applicable, the Department of Rehabilitation Services
provides Phase One of supported employment and DDSD provides the stabilization. In other
cases, DDSD provides for the employment services.

       Employment services covered by the waivers include the following:

      Employment Training Specialist- This service provides individual job coaching to
       persons who need 100% assistance on the job. It is available for six weeks annually.
      Center-Based Services- Services are provided in segregated settings where the majority
       of people served have a disability.
      Community-Based Services- These services are provided in the community and are pre-
       work type experiences to allow the individual to volunteer, job shadow, or receive
       training through generic vocational training programs and other types of job exploration
       or generic training and experiences.
      Job Coaching- This service promotes the person’s capacity to secure and maintain
       integrated employment at a job of the person’s choice paying at or above minimum wage.
       Job coaching services are available at both the individual and group level. Group
       placements of two to eight individuals needing continuous support at an integrated work
       site are included in job coaching services even though the individuals may earn less than
       minimum wage (enclaves).
      Enhanced Job Coaching- Enhanced rates are available for persons with special behavioral
       or medical needs.
      Stabilization- These services are ongoing support services needed to maintain one or two
       service recipients in an integrated competitive employment site. Stabilization services
       are provided for up to two years per job. Services can be extended if needed on the plan
       of care.

        According to the interviewee, the DDSD and the Department of Rehabilitation Services
have an excellent working relationship. Persons with developmental disabilities can move from
services funded by one agency to the other agency easily. Vocational rehabilitation services are
often provided for Phase One with the waiver services providing the stabilization. Of the people
involved in employment services, about 60% are in individual competitive employment. DDSD
has a policy that all persons under the age of 65 and living in a residential program must work up
to 30 hours of employment per week.

                                             A - 26
        Job coaching services for individual placements are paid on an hourly basis (actually
quarter hours rolled up to hours) when on-site supports by a job coach are provided for more
than 20% of the individual’s compensable work time. The job coaching services are provided
until the person needs assistance less than 20% of the time on the job or has worked four
consecutive weeks on the job. Rates for individual placement in job coaching services are
$16.00 per hour and are paid for the number of hours the person works per week. For example,
if the person works 20 hours per week, the job coaching services would cost $320.00 per week.
Group rates are set at a lower amount of about $14.00 calculated in the same manner.

         Stabilization services are provided when the job coach intervention time required at the
job site is 20% or less of the service recipient’s total work hours, or when the person moves from
vocational rehabilitation services to the waiver. Stabilization services are funded at $5.00 per
hour and are calculated using the same formula as above. If a job coach is providing
stabilization services for an individual who is working 30 hours a week at minimum wage, the
job coaching service would be billed at $150.00 per week. The rate is not based upon contact
hours between the job coach and the person receiving services. It is a flat hourly rate based upon
the number of hours that the person is working. This is an excellent way to allow providers to
predict the income associated with providing stabilization services and encourages the provider
to try to assist the individual to work as many hours as they wish.

        In prior years, group placements and individual placements were paid at the same rate.
To encourage more individual placements, the state completed a survey of costs and split out the
rates for individual placements. They purposely set the rate for individual placements higher
than group placements to incentivize the development of individual job development.

         The individual training specialist rate is billed at $21.85 per hour and is billed based upon
direct contact with the individual. This service is used when the person requires a one-to-one
ratio to learn how to complete the job. It is limited to six weeks.

       Enhanced rates are available for persons with behavioral and medical special needs.

        Oklahoma provides two state-funded services for persons on the waiting list—supported
employment and workshop. The workshops are paid at $21.00 per day per recipient. The state
also has an agreement with Vocational Rehabilitation that this agency will work with the schools
providing the Phase One job development services.

         Prior to re-working the rates, families and providers were raising issues regarding the
rates. Now that the rates have been adjusted, DDSD has not heard many complaints. Families
are worried about the raise of the minimum wage, regarding how it will impact providers, and if
it will negatively impact the availability of jobs for persons with developmental disabilities.




                                               A - 27
                        Oklahoma Department of Rehabilitation Services

       The Oklahoma Department of Rehabilitation Services pioneered the results-based
payment method currently used in several state vocational rehabilitation programs. The
―Milestone Payment System,‖ as it was named in Oklahoma, provides payment to providers for
achieving pre-designated steps in securing a job for persons with disabilities. The state started
working on this initiative in 1992. Unfortunately, the person currently responsible for this
system was not available for an interview. Several calls and messages were left, but there was
no response. However, this system has been researched and discussed at length in the literature.
The state also has a website that provides information on payment structure.

       According to the information on the website, the Oklahoma Department of Rehabilitation
Services was discouraged with the fee-for-service payment system and thought that the system
created perverse incentives that worked against the overall goal, which was competitive
employment with the least amount of professional support.

        The Department found that developing realistic operational definitions of the outcomes of
service that could be subdivided into incremental outcomes or ―milestones‖ was very difficult.
They worked in collaboration with the providers throughout the project. They developed five
milestones and tied a percent of the payment to them. Below is a chart showing this payment
structure.

                                       Milestones                                       Payment
1.     Assessment
       • Computerized progress report
                                                                                          10%
       • Situational assessment reports and/or vocational assessment forms
       • Summary vocational assessment report or vocational profile
2.   Job placement
       • Computerized progress report
       • Employment verification form signed by employer                                  15%
       • Task analysis form
       • Job analysis form
3.   Job retention at four weeks
       • Employment verification form (verification of continued employment and
                                                                                          15%
           hours worked per week is required for payment)
       • Computerized progress report
4.   Job retention at ten weeks
       • Employment verification form (verification of continued employment and
                                                                                          15%
           hours worked per week is required for payment)
       • Computerized progress report
5.   Stabilization
     The following must be verified:
       • The individual has been employed for a total of at least 17 weeks                20%
       • A written employer evaluation has been submitted, which indicates acceptable
           job performance during the most recent month


                                              A - 28
       •   A current Client Job Satisfaction Questionnaire has been submitted which
           indicates client/family satisfaction
       • The individual has received support services defined in the IRP, including a
           minimum of two individual contacts and one employer contact per month
       • The individual has worked at least two entire shifts without job coach support
           in one week, as verified in the employer evaluation (may be waived by the
           DRS Counselor if the consumer meets criteria for highly challenged)
       • The individual has met the weekly work goal in the IRP
6.   Closure
     The following information must be submitted
       • Current employer evaluation form                                                    25%
       • Current computerized progress report
       • Current client job satisfaction questionnaire
                     (Adapted from Frumkin, 2001 and Novak, Mank, Revell, & O’Brien, 1999)

        The Milestone Payment System is based upon a bidding process through which the
providers determine their estimated costs to reach closure. The estimated cost is applied across
the five milestones and a percentage of the cost is paid for each. To ensure that persons with
very serious disabilities were served, the state established a tiered system for persons that need
extensive supports.

                                               Sources

1. Regina Chace- Department of Human Services, Developmental Disabilities Service Division.
2. Frumkin, P. (2001). Managing for outcomes: Milestone contracting in Oklahoma.
   Retrieved September 3, 2007, from the Oklahoma Department of Rehabilitation Services
   website: http://www.onenet.net/~home/milestone/Harvard%20-%20FrumkinReport.pdf
3. Novak, J., Mank, D., Revell, G., & O’Brien, D. (1999). Paying for success: Results-based
   approaches to funding supported employment. In G. Revell, K. J. Inge, D. Mank, &
   P.Wehman (Eds.), The impact of supported employment for people with significant
   disabilities: Preliminary findings from the national supported employment consortium (pp,
   25-42). Retrieved September 3, 2007, from Virginia Commonwealth University
   Rehabilitation, Research, and Training Center on Workplace Supports and Job Retention
   website: http://www.worksupport.com/research/viewContent.cfm/111
4. Section 317:40-1-1 Oklahoma Administrative Code
5. Section 317:40-7-3 Oklahoma Administrative Code
6. Oklahoma Department of Human Services Developmental Disabilities Division. (2006).
   Employment Services Rate Increases. Retrieved September 3, 2007, from
   www.okdhs.org/programsandservices/dd/prvdrs/docs/employeesvcs2006.htm
7. Oklahoma Department of Rehabilitation Services. (1999). Milestone payment innovation
   program. Retrieved September 3, 2007, from Oklahoma Department of Rehabilitation
   Services website: http://www.onenet.net/~home/milestone/mlstinov.html




                                               A - 29
           Supported Employment Payment Structures and Incentives – Oregon

         Seniors and People with Disabilities Division, Department of Human Services

        Oregon operates two Home and Community Based Services for persons with
developmental disabilities. The original waiver is a comprehensive program for persons either
living in their own home or with their family or in a 24-hour residential program. The waiver
includes supported employment as one of the services. The second waiver, known as the Self
Directed Support Services for Adults or the Brokerage Model, was implemented as part of a
settlement agreement from Staley v. Kitzhaber. This waiver allows the individual to direct the
purchase of their services. The purpose of the agreement was to eliminate or significantly reduce
the number of individuals with developmental disabilities waiting for services. Service costs for
persons on the support services waiver are capped at $20,000. The agreement included the
development of the support service waiver and the addition of a limited number of persons onto
the comprehensive waiver on a non-crisis basis. Supported employment is included in the
support service waiver as well.

       Supported employment is defined as services to assist an individual to choose, get, and
keep a paid job in an integrated community business setting. Supported employment services
include:

      Work exploration
      Job development
      Training and ongoing supervision to obtain paid employment
      Training that may focus on the individual worker and on co-workers without disabilities
       capable of providing natural support
      Retraining that may be required due to a change in work environment

       The comprehensive waiver operates on a more traditional basis, in which the counties
contract with providers on a fee-for-service basis, based upon an annual amount per person.
Services are paid using a daily rate. The rate schedule for this waiver could not be found on the
web.

        The Oregon rate schedule for the support services waiver outlines a range of rates for
their services. Providers are required to set their rates and consumers choose to purchase these
services. The services provide for individual time-limited Phase One supported employment
services and individual ongoing supported employment. The state also provides enclaves or
crew, facility-based socialization, and facility-based employment. Services are paid on an hourly
basis and require contact with either the individual or the supervisor or co-worker. The rates for
these services are different, depending on how they are purchased through (a) an individual
employed by the person, (b) an independent contractor, or (3) a provider organization. The table,
below, provides the rate ranges for these services through June 2008.


                                              A - 30
                                                           Rate Range
                                Individual Employed
                                                            Independent           Provider
Type of Service                      by Service
                                                             Contractor          Organization
                                  Recipient/Family
Job Development and                 Minimum Wage
                                                           $12.94 to $34.49     $15.63 to $43.13
Placement                             To $13.22
                                    Minimum Wage
Job Exploration                                            $12.94 to $34.49     $15.63 to $43.13
                                      To $13.22
Job Coaching or                    Minimum Wage
                                                           $12.94 to $34.49     $15.63 to $43.13
Employment Consultation              To $13.22
                                   Minimum Wage
                                     To $13.22
                                         OR
Individual Ongoing
                                Payment of Co-worker/      $12.94 to $34.49     $15.63 to $43.13
Supported Employment
                                  Business based on
                                      formula
                                SPD IM 04-017 3/14/04
                                                                               Hourly rate ranges,
                                                                               above, prorated by
                                                                              number in the group
                                                                                  OR daily, at:
                                                                                $29.11 to $39.89
Enclave or Crew                                                               NO MATTER RATE
                                                                                   METHOD,
                                                                                  MAXIMUM
                                                                                  PAYMENT
                                                                                  ALLOWED
                                                                                  $39.89/DAY
Facility-Based Employment                                                       $29.11 to $39.89

Facility-Based Socialization                                                    $29.11 to $39.89


         According to the person interviewed from the Oregon ARC, the state needs to continue to
stress the development of employment opportunities. The Oregon Council for Developmental
Disabilities completed a study in 2005 that provides ―workable solutions‖ to increase supported
employment in Oregon. They found that rate structures were contributing to limited supported
employment opportunities. These findings are summarized below:

       Rate structures under the support service waiver have inconsistencies in rates between
        time-limited and long-term supports, creating a disincentive for providers to offer follow-
        along services.




                                              A - 31
      Rate structures under the comprehensive waiver pay providers on a blended rate that does
       not take into account individualized needs or the real cost of services. Distribution of
       funding should be based on individual needs and services provided.

       The state has decided to totally redesign their Comprehensive Home and Community
Based Waiver and has given the initiative the title ―ReBAR.‖ They are using a systematic
approach to develop mechanisms to tie payment to the needs of the individual. They hope to
develop assessment mechanisms that will help predict levels of need in the creation of individual
budgets. Their goal is to establish a way to allocate resources to individuals and providers. They
also hope to have a tiered system that will account for the medical and behavioral needs of
individuals.

                               Office of Vocational Rehabilitation

        The staff person that knows the most about supported employment in Vocational
Rehabilitation was not available to be interviewed during the period of this review. Oregon has
received a four-year Medicaid Infrastructure Grant from the Center for Medicare and Medicaid
Services. The project is supporting the Seniors and People with Disabilities Division in a multi-
year initiative to improve supported employment services for persons with developmental
disabilities. This project is known as ―ReBAR‖ and is discussed above. As part of this effort,
the Seniors and People with Disabilities Division has joined the State Employment Leadership
Network. According to the interview with Molly Hollsapple, the results of this work will not be
available until next calendar year.

                                             Sources

1. Interview with Mariah Forrest and Molly Holsapple, Seniors and People with Disability
   Division
2. Interview with Marcia Ingledue, Executive Director of the ARC of Oregon
3. ―The Basics About Self-Directed Support Services for Adults‖,
   www.orcoregon.org/staley.htm
4. ―Oregon Competitive Employment Project, Oregon Department of Human Services‖, Office
   of Vocational Rehabilitation
5. State Employment Leadership Network, Rates and Reimbursement Group Working Paper
6. ―Supported Employment for Oregonians with Development Disabilities: Recommendations
   for Action,‖ Oregon Council on Developmental Disabilities, November 2005
7. Supported Services Rate Table, 2007-08




                                             A - 32
           Supported Employment Payment Structures and Incentives -Vermont

       Vermont is well known as a state that no longer operates group day programs and now
has only individual programs for persons with developmental disabilities. The Developmental
Disability program and Vocational Rehabilitation combine their funds to create a seamless
system for employment by providing grants to 16 local developmental disability provider
agencies to provide the full range of supported employment services. The grants supported by
Vocational Rehabilitation dollars provide funding for leadership and staff to work in the
community to locate jobs and to market supported employment. Staff also provide direct
services when necessary.

                           Division of Disability and Aging Services

       The Vermont supported employment program for persons with developmental disabilities
includes transportation, assessment, job site support, job development, job replacement, self-
employment, and follow-along services. The Vermont Medical Home and Community Based
Waiver funds all the supported employment services provided by the Division. Vocational
Rehabilitation also funds supported employment programs through their federal and state funds.
The state does not fund group day programs. They do, however, operate space for personal
needs. These include small rooms that are located in the towns that provide a place for persons
with developmental disabilities to meet with friends or support workers.

        People are eligible for the Home and Community Based Waiver if they have a
developmental disability and meet one of the system of care’s funding priorities. Examples of
these priorities include:

      health safety risks (can’t be home alone),
      adjudicated to the Commissioner (sex offenders),
      graduated and has a job,
      risk of homelessness (broadly interpreted), and
      parent who has a developmental disability.

        The interviewee provided clarification regarding the high school graduate requirement to
have a job. The supported employment community staff begin working with the students before
graduation and usually have a job lined up by then. Between Vocational Rehabilitation
resources and the Home and Community Based Waiver, most young adults transitioning from
high school receive funding.

       Although the state does not offer day habilitation group-based programs, they do offer
non-work options. The waiver includes a service called ―community support services‖ that can
provide an average of 25 hours of supervised activities per week. These services are
individualized and include volunteering in a work setting, socialization, recreation, etc.
Currently, 37% of working age adults are in employment earning about $7.86 an hour for an

                                             A - 33
average of ten hours per week. According to the report, the average hours per week required to
provide supports for adults with developmental disabilities work has been decreasing steadily
over the last several years. Vermont reports that 43% of those people with developmental
disabilities receiving community supports are employed. The remaining number are either
receiving community support services, residential programs, or other services.

       Vermont does not use financial incentives for the provider, but does apply incentives to
individual funding levels. If a person wishes to convert at least 50% of their community support
services to employment-related services, then the state will increase their annual amount for their
individual plan by $5,000 per year, which will be carried forward each year. This approach has
been very successful in motivating people toward employment.

        Vermont’s system for persons with developmental disabilities is very individualized and
person-driven. The individuals, with those that know and care about them, work with staff to
develop a very personalized individual plan. If the person has been receiving services over the
last year, their services are covered in the agency’s budget, which is allocated to them each year.
This budget is based upon the needs of persons currently in their agency plus an inflation factor
provided through the state legislature. The provider agencies set the rates for services that will
be billed as part of the individual plan. The providers submit a monthly bill to the Division for
the cost of service for each individual served on a monthly basis. The bill includes the specific
services provided, but the agencies are reimbursed based upon a ―per individual‖ cost.
According to the interviewee, the average cost for persons receiving supported employment is
around $29,000. In estimating costs, the general rule of thumb is for every hour per week on
supported employment, assume $1,000 annual cost. The Annual Report of 2007 states that the
average cost for people receiving all services is $32,321 with 46% served for less than $20,000.
The total number served in 2006 was 3,224.

        Intake and assessment are provided to new people coming into the system, after intake
testing is conducted to ensure that the person meets the categorical eligibility for developmental
disabilities. Once they are determined eligible, a needs assessment is completed that guides the
development of the individual plan and associated costs. These plans are then presented to a
state level Equity Committee composed of rotating Executive Directors from the local
community agencies. This committee authorizes the services or makes recommended
adjustments to the cost. This process should take about 45 days, although lack of credentialed
psychologists may cause delays in eligibility determination. There is a separate budget
maintained at the state level to address the needs of new individuals. At the local level, the
provider agencies must stay within their budgets.

        The 16 designated provider sites have staff who are funded by Vocational Rehabilitation
that also provide supported employment services. They also perform many of the job placement
and other supported employment activities. These costs are not associated with the Home and
Waiver cost but instead are attributed to the grant. According to the interviewee, these grants

                                              A - 34
have made a significant contribution to their success in supported employment. Also,
Disabilities and Vocational Rehabilitation work very closely together and are able to move
people from waiver-supported services to Vocational Rehabilitation supported services very
easily.

       Quality improvement is conducted by on-site reviews of all Medicaid-funded services
provided by each agency. The quality review teams assess the quality of services with respect to
the Division’s quality goals and outcomes to assure compliance with state and federal Medicaid
standards and individuals’ desire for their supports. The quality of individual services is
evaluated, as well as systems and organizational issues. Although Vermont reports high levels of
employment, one of the priority areas for improvement noted from the on-site reviews is
employment services.

       The interviewee thought that the providers are having a hard time keeping up with the
pressure for more people to have jobs. Families are probably fairly happy with the job situations
but would like more upward mobility and ability to change jobs when they would like. Also, the
job market may be getting saturated and may not have the capacity to handle too many more
people. The grant from Vocational Rehabilitation has not increased over the last few years. The
ARC of Vermont is no longer operational, so interviews were not possible.

                              Division of Vocational Rehabilitation

        As stated above, the interagency work between Vocational Rehabilitation and Disabilities
creates a blended system of services at the 16 provider sites. The Vocational Rehabilitation
program provides grants to the providers to provide supported employment and not through a fee
for service basis. The grants are outcome-based and require a minimum number of outcomes
and number served. The providers make the decisions regarding the provision of services rather
than referrals being made to the Vocational Rehabilitation counselors. Vocational Rehabilitation
monitors the outcomes. They also measure the rate of success, how services are integrated, how
they are completing outreach, and measurement of progress on improving quality. The providers
bill Vocational Rehabilitation on a quarterly basis.

       The Vocational Rehabilitation grant also funds leadership activities. The Vocational
Rehabilitation staff person is the President of the local APSE in Vermont.

       For youth transitioning out of high school, there are 16 counselors at the local level who
work with the schools to help people make this transition. The grants are supplemented to help
with the transitioning. Much of the State Vocational Rehabilitation is funded by state dollars.
Vocational Rehabilitation does not provide any financial incentives to providers.

       According to the representative from Vocational Rehabilitation, the mission and
philosophy have driven the change to a work-oriented system.



                                              A - 35
                                           Sources

1. State of Vermont, Department of Disabilities, Aging, and Independent Living. (2006).
   Annual report. Retrieved September 5, 2007, from: http://dail.vermont.gov/dail-
   publications/publications-annual-reports/annual-report-2006

2. Interview with Gary McClintoc- Vermont Division of Vocational Rehabilitation

3. Interview with Jennie Masterson- Vermont Division of Disability and Aging Services




                                           A - 36
         Supported Employment Payment Structures and Incentives - Washington

                              Division of Developmental Disabilities

       The Division of Developmental Disabilities has developed a policy that states that
persons with developmental disabilities will be supported to achieve a greater measure of
independence through a uniform and coordinated system of services. The policy establishes
employment supports as the primary use of day program funds for working wage adults (State of
Washington Policy 411). The Division has four Home and Community Based Waivers and
supported employment is included in each of these waivers.

        The Division of Developmental Disabilities is a county-based system in which the county
receives an allocation from the state to manage their services. According to the interviewee, the
counties operate their programs within budget. The state also tracks the expenditures on a
monthly basis. All service contracts and payments go through the county system. The counties
reimburse the providers and then submit their billings to the state. The providers do not bill
Medicaid directly. The counties pay for supported employment services through either monthly,
hourly, or on a per-contact basis. The counties are expected to stay within an average of $510
per month. In some cases, the amount can exceed this limit if the person needs more services
upfront. Most of the supported employment services provided by the Division are for extended
service. The counties are required to monitor the contracts every two years.

       The services provided under supported employment include the following:

      group supported employment,
      individual competitive,
      pre-vocational (sheltered workshop), and
      Person-pathway to work discovery.

        According to the person that was interviewed from the Division, 41% of the people
served in the above categories are served in individual competitive employment. He stated that
the policy that clearly established the expectation for the individual model significantly
contributed to their success. They have a good partnership with Vocational Rehabilitation that
provides the Phase One services for many recipients. The Division also provides Phase One
services if they are not available through Vocational Rehabilitation.

        Payment for supported employment services is funded by only state funds and Medicaid
dollars. Also, the legislature funds through state dollars a special program for youth transitioning
from high school to work.

      The state does not pay bonuses or incentives; however, a couple of counties do provide
some bonuses for successful work placements.



                                              A - 37
        The person interviewed stated that the family members and persons receiving services are
excited about the work opportunities. Other family members state that they prefer sheltered
employment. One problem related to independent work environments that can result in
challenges for families is providing supervision when the person with developmental disabilities
is not working. The state and counties encourage the use of generic services and work with the
families in planning the jobs.

       Some providers have been resistant to the move to individual employment and do not
believe that reimbursements are adequate to cover the cost of services.

        The interviewee believes that their success is due to the amount of training and technical
assistance that they have provided. They have used technical assistance from the University of
Vermont to help them increase the successful use of natural supports. Some of the local
businesses have adopted the philosophy of supported employment and have encompassed the
extended services as part of the business through supervision and co-workers. These businesses
include Starbucks, Microsoft, and Boeing.

                              Division of Vocational Rehabilitation

       The Division of Vocational Rehabilitation is also committed to providing supported
employment services for persons with developmental disabilities. They provide the following
supported employment services:

      assessment
      trial work experience
      job placement
      job coach (one-on-one intensive training)
      post-employment after closure.

       There are flex funds for other services that might be necessary for employment, such as
uniforms, tools, transportation, etc.

        The use of Vocational Rehabilitation funds is fairly fluid. There are no timelines or
limitations on the number of times that a person can receive vocational rehabilitation service.

        Services are provided by vendors with the exception of some assessments. In some
cases, the Vocational Rehabilitation counselor provides the assessments, and in some cases, they
purchase the services. The Washington Vocational Rehabilitation program pays for services
through a tiered level of services. They have set fees and pay based upon outcomes. Both of the
agencies are in the same department, which helps coordinate programs. However, Vocational
Rehabilitation operates as a state level program while the Developmental Disabilities program is
a county-based service system. According to the Vocational Rehabilitation staff member, most
of the counties pay for extended services on a monthly basis. She thinks that this approach

                                              A - 38
should be tiered to leverage supported employment services. Also, the focus on natural supports
is important but is much harder to establish and maintain than purchased extended services. The
other problem with the integration with Developmental Disability services is that not all the
Vocational Rehabilitation recipients with developmental disabilities are eligible for services.
However, some of these individuals can benefit from employment services and do not require
extended services. The state Vocational Rehabilitation program does not provide incentives, but
the counties are able to do so if they wish. King County does provide some incentives for
successful closures.

       The legislature provides special state funding for youth coming out of school. All
students are transitioned to a work environment. The Vocational Rehabilitation counselors start
working with youth while they are still in school.

        Performance measurement is limited. They are able to track closures, what services are
provided, what type of jobs were obtained, what type of wages are earned, etc. They would like
to be able to more closely monitor outcomes by case rather than by provider.

        The counties have complained that the Vocational Rehabilitation program is impatient in
closing cases, and that their general ―rule of thumb‖ that if no progress has been made in six
months then the case should be closed is too strict. Both the Division of Developmental
Disabilities and the counties would prefer that Vocational Rehabilitation provide services for as
long as it takes to obtain a successful closure. Sometimes , there is also disagreement about
whether the employment is a successful closure. The Developmental Disability agency would
like to have a broader acceptance of self-employment or family business type options.

        The representative from the Washington ARC believes that the state is doing a good job
in providing employment and basically supports the policy that promotes work. Some families
and persons with developmental disabilities prefer the sheltered workshops because of the
predictable schedule when they have no assistance to provide supervision during non-work
hours. Also, families are concerned that, by working, persons might be risking their benefits and
Medicaid coverage. The sheltered workshops are beginning to close, but not because of
supported employment. The assembly work is being shipped offshore. The ARC representative
stated that more funding needs to be available to provide supervision and meaningful activities
for non-work activities.

                                             Sources

1. Interview with Doug Washburn from the Division of Developmental Disabilities

2. Interview with Kelly Baston from the Division of Vocational Rehabilitation

3. Interview with Sue Elliot from the ARC of Washington



                                             A - 39
         Appendix B

Sample Interagency Agreements
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MEMORANDUM OF AGREEMENT
                     STATE OF NEW MEXICO
         NEW MEXICO PUBLIC EDUCATION DEPARTMENT,
           DIVISION OF VOCATIONAL REHABILITATION;
             NEW MEXICO DEPARTMENT OF HEALTH,
        DEVELOPMENTAL DISABILITIES SUPPORTS DIVISION

This Memorandum of Agreement is made between the New Mexico Public Education
Department, Division of Vocational Rehabilitation, hereinafter referred to as ―DVR‖, the New
Mexico Department of Health, Developmental Disabilities Supports Division, hereinafter
referred to as ―DDSD‖.

The parties to this Agreement, in consideration of the mutual covenants and stipulations set out
herein, agree as follows:

                                         SECTION ONE
                                      Purpose of Agreement

DVR and DDSD agree that the purpose of this Agreement shall be to accomplish joint
implementation for supported employment under: the Rehabilitation Act of 1973, as amended,
29 U.S.C 795(b)(1) and 721 (a)(11); 8.314.5 NMAC and Walter Stephen Jackson, et.al. vs. Los
Lunas Center for Persons with Developmental Disabilities, et.al. CIV No.87-0839-JP/LCS

                                         SECTION TWO
                                           Definitions

Competitive Employment - Work in the competitive labor market that is performed on a full-
time or part-time basis in an integrated setting; and for which an individual is compensated at or
above the minimum wage, but not less than customary wage and level of benefits paid by the
employer for the same or similar work performed by individuals who are not disabled.

Developmental Disability - A significant chronic disability, other than mental illness, of a person
that:
    1. Is attributable to a mental or physical impairment, including the result from trauma to the
       brain, or combination of mental and physical impairments;
    2. Is manifested before the person reaches the age of twenty-two years;
    3. Is expected to continue indefinitely;
    4. Results in substantial functional limitations in three or more of the following areas of
       major life activities:
           A. self-care,
           B. receptive and expressive language,
           C. learning,
           D. mobility,
           E. self-direction,
           F. capacity for independent living,
           G. economic self-sufficiency, and


                                              B - 20
    5. Reflects the person’s need for a combination and sequence of special, interdisciplinary
       generic care treatment or other support and services that are of life long or extended
       duration and are individually planned and coordinated;

        OR:

    6. Is a person who is eligible for services based on any previous definitions used by the state
       and was receiving services on the effective date of the Developmental Disabilities Act.

DVR/DDSD Supported Employment Client – An individual with a most significant disability
who is eligible for supported employment services through DVR and DDSD.

Employment Specialist/Job Coach – The individual responsible for providing intensive on-the-
job training and ongoing support of the supported worker with the most significant
disability(ies). The Employment Specialist functions may include: job development;
task/position analysis; environmental analysis; job analysis; development of a vocational profile
and career development plan; this may include a DDSD approved substitute profile and plan;
matching of worker-job characteristics; advocacy, including the fostering of worker/co-worker
relationships; transportation training/assistance; family counseling and extensive monitoring of
worker progress. The Employment Specialists bring the job development, placement and
training functions to stabilization with ongoing support services being provided by a Follow-
Along Specialist.

Evaluation of Rehabilitation Potential for Supported Employment – An assessment for
determining eligibility and vocational rehabilitation service needs. Relevant information should
be utilized, including information obtained to evaluate basic vocational rehabilitation potential
and to determine eligibility for supported employment. An additional evaluation of
rehabilitation potential is unnecessary if the counselor has sufficient information to determine
eligibility and develop the Individualized Plan for Employment. The evaluation should include a
review of the individual’s Individual Service Plan to include his/her vision, functional
assessment and a vocational profile; this may include a DDSD approved substitute profile and
plan.

Individual Service Plan – A comprehensive plan for services and supports for individuals with
disabilities, that includes life goals, needs, skills and interests of the individual using services,
and supports strategies and resources identified to help the individual achieve his/her goals.
Major life domains, including employment/vocation are part of the ISP

Integrated Work Setting – A job site where:
    1. Most co-workers are not disabled; and
    2. An individual with the most significant disability(ies) interacts on a regular basis, in the
        performance of their job duties, with employees who are not disabled; and
    3. The interaction required MAY NOT be satisfied by contact between an individual with
        the most significant disability(ies) and paid support staff.



                                                B - 21
Jackson Class Member – An individual resident at Ft. Stanton or the Los Lunas Center for
Persons with Developmental Disabilities whom for that reasons was deemed a plaintiff class
member for purposes of the Jackson lawsuit.

Most Significant Disability(ies) – Supported Employment is specifically designed to overcome
impediments to employment for persons with the most significant disability(ies). Persons with
the most significant disability(ies) is an individual that meets the following condition:
    Has a significant physical or mental impairment, which in terms of an employment outcome,
       significant impedes the individual’s functional capacities in two or more areas (e.g.,
       mobility, communication, self-care, self-direction, interpersonal skills, cognitive ability
       or work tolerance), and
    For whom competitive employment has not traditionally occurred or has been interrupted or
       intermittent, and
    Whose vocational rehabilitation can be expected to require multiple and intensive vocational
       rehabilitation services over an extended period of time in order to result in an
       employment outcome.

Natural Supports - Supports that enhance an individual’s success in all aspects of daily living,
including employment. These supports are not reliant on, or controlled by the funding agencies
or program resources. Examples include, but are not limited to: personal social networks,
families, friends, co-workers, supportive environments, , and employer practices that promote
teamwork.

Ongoing Support Services - Services that are:
   1. Needed to support and maintain an individual with significant disabilities in supported
      employment,
   2. Based on a determination by the designated State unit of the individual’s needs as
      specified in an Individualized Plan for Employment; and
   3. Furnished by the designated State in 34 CPR 363.4(c)(3) and following transitions, by
      one or more extended services providers throughout the individual’s term of
      employment in a particular job placement or multiple placements if those placements are
      being provided under a program of transition employment.
   4. Include, at a minimum, twice – monthly monitoring to assess employment stability at
      the work site of each individual in supported employment (unless the Individualized
      Plan for Employment provides for off-site monitoring), and based upon that assessment,
      the coordination or provision of specific services at or away from the work site, that are
      needed to maintain employment stability. If off-site monitoring is determined to be
      appropriate, there must be contact with the employer each month

Vocational Assessment - Information on an individual’s life experiences, preferences and
interests gathered through a person-centered planning process that is analyzed to highlight the
most significant themes and contacts that relate to assisting the individual to access employment
in the community.

Pre-Placement Activities - These services may include job development, vocational profile
development, career development planning, and other pre-employment services.


                                              B - 22
Start-ups – An individual who is eligible for DVR supported employment services and placed in
a job (starts working).

Supplemental Assessment – An assessment that is supplemental to the comprehensive
assessment of Rehabilitation Potential and is provided subsequent to the development of the
Individualized Plan for Employment. Supplemental assessments may be provided in those
circumstances, such as, where a reassessment of the suitability of the client’s placement is
needed or if there is a change in the individual’s psychiatric condition.

Supported Employment – Competitive work in an integrated work setting with ingoing support
services for individuals with the most significant disability(ies) for whom competitive
employment:
    1. Has not traditionally occurred; or
    2. Has been interrupted or intermittent as a result of significant disability; and
    3. Who, because of the nature and severity of their disability, need intensive supported
       employment services or extended services in order to perform and maintain such work.

Vocational Profile: An alternative to more traditional vocational evaluations, which enhances
the IPE, by providing additional information which can be used as the basis for job development
and individualized career development. A corresponding career development plan; that is
consistent with the vocational profile; includes strategies to improve accountability,
employment outcomes, the use of natural supports and networking, and provides a framework
for counselors to precisely monitor progress, and make appropriate resource decisions regarding
the implementation of the IPE.

                                       SECTION THREE
                                          Eligibility

I. DVR eligibility criteria for vocational rehabilitation services is:
   The applicant must have a physical or mental impairment,
   Which constitutes or results in a substantial impediment to employment, and
   Vocational Rehabilitation Services are required to prepare for, secure, retain or regain
      employment, and
   The individual can benefit in terms of an employment outcome from vocational rehabilitation
      services.

II. DVR eligibility criteria for Supported Employment is:
    1. The individual must meet eligibility criteria for vocational rehabilitation services, and
    2. The individual must be found to have a most significant disability(ies), and
    3. Employment must not traditionally have occurred or must be either interrupted or
       intermittent, and
    4. Because of the nature and severity of their disability there is the need for intensive
       supported employment services or extended services in order to perform and maintain
       such work, and



                                              B - 23
   5. Availability of long-term term support is identified or can be anticipated by the time
      DVR is ready to close the case.

III. DDSD Eligibility for the purposes of this agreement is as follows:
     1. The individual has a developmental disability and mental retardation or a specific related
        condition.
     2. Specific related conditions are limited to cerebral palsy, autism (including asperger
        syndrome), seizure disorder, chromosomal disorder (e.g. down syndrome), syndrome
        disorders, congenital errors of metabolism and developmental disorders of brain
        formation.

                                       SECTION FOUR
                             Method of Accomplishment of Purpose

I. The Developmental Disabilities Supports Division shall:

   1. Implement and maintain a referral process including the following:
         A. Require DDSD contractors to refer individuals who meet referral guidelines for
            employment to DVR. Individuals will have work goals, or interest in working, as
            documented in their ISPs.
         B. Continue to implement current regulations that require that persons who have not
            been previously in the DVR system, be referred to DVR prior to receiving DD
            waiver services for supported employment. This does not preclude individuals
            who have previously received DVR services to be referred again if warranted.
         C. Require IDTs to work with the individual to complete the DVR ―Client Brief
            Sheet‖ (attachment #1) and provide other referral and intake information to DVR,
            including any required release of information.
         D. Coordinate as needed with IDTs and DVR field staff to provide additional
            information such as vocational assessments, level of care form, ISP and budget, to
            establish eligibility and develop the IPE.
         E. Offer through IDTs and contractors on-going support to individuals who have
            received job development services, and initial on-the-job training, as specified in
            their IPEs and provided through DVR.
         F. Set annual targets for employment outcomes including specific Jackson Class
            Members who have work goals but are not working, in collaboration with DVR,
            and meet on a regular basis to identify successes and implementation issues to be
            addressed.

   2. Offer long-term support:
         A. DDSD shall offer through its contractors long-term ongoing support services.
              This may include: transportation, personal care, counseling to family members,
              and job skills/job coaching services at the worksite after DVR funding has ended.
         B. DDSD shall provide DVR written verification prior to June 30th of each year that
              Supported Employment Medicaid Waiver or State General Funds are available for
              potential DVR/DDSD supported employment clients, as well as the names and
              locations of employment facilities and vendors of supported employment services.


                                              B - 24
   3. Implement additional responsibilities to carry out this agreement:
         A. DDSD shall maintain specific liaison staff with statewide and regional
            responsibility for monitoring and implementing this agreement including
            facilitation of employment for Jackson Class Members.
         B. Collaborate with DVR to train appropriate staff: DVR Counselors and
            Supervisors, DDSD staff and DDSD funded Case Managers and Supervisors, and
            supported employment agency personnel.
         C. Provide outreach training and information to families, individuals, guardians and
            advocates on employment and supports to employment.
         D. Disseminate this agreement to all relevant DDSD staff, and facilitate regional
            discussions in conjunction with DVR, to clarify the purposes, intent, and
            responsibilities of the two agencies in implementing this agreement. An emphasis
            will be placed on referrals of Jackson Class members with identified employment
            goals.
         E. Provide information to DVR as delineated in this agreement.
         F. Work with DVR to identify alternative vendors, including new providers who
            specialize in individualized job development and job placement. Emphasis will
            be placed on areas of the state where there are few or no quality outcomes and
            innovative approaches.
         G. Advise DVR Supported Employment Coordinator of selected team meetings of
            Jackson Class Members whose teams may not be supportive of work and assist
            individuals to consider other provider options if necessary. DVR Supported
            Employment Coordinator will ideally be provided 8-10 weeks notice, but in no
            event less than 4 weeks notice of these meetings.
         H. Implement DDSD’s ―Employment First‖ policy and maintain employment focus
            for class members and others who have work goals. Provide technical assistance,
            in collaboration with DVR, to individuals and teams in the implementation of the
            policy.
         I. Review shared cases at the local level and collaborate with DVR to solve
            individual and systemic issues.

II. The Division of Vocational Rehabilitation or their contractors shall:
    1. Target outcomes, in conjunction with DDSD, on an annual basis for specific Jackson
       Class Members who have work goals but who are not working and collaborate with
       DDSD to obtain employment for them.
    2. Accept and process individuals referred by DDSD:
           A. For those individuals who are determined eligible, develop IPEs and provide
               vocational services as appropriate.
           B. Coordinate service delivery with the individual, the family or
               advocate/representative, DDSD and other community providers as appropriate.
           C. Provide a bi-annual status report to DDSD regarding individuals referred under
               this agreement.
           D. Institute milestone payments by DVR to eligible vocational rehabilitation
               providers with individual rates for Jackson Class members and separate rates for
               all other referrals through this agreement.


                                             B - 25
           E. Provide short-term services, generally not exceeding 18 months, with the goal of
              appropriate job placement.

   3. For those Jackson Class Members referred by DDSD, DVR will take the lead in getting
      an employment assessment/profile completed for job development. DVR will assist in
      obtaining employment in conjunction with DDSD.
   4. Take the lead in developing and implementing quality vocational assessments for Jackson
      Class Members who do not have referral information meeting the criteria defined in this
      MOA under ―Vocational Profile‖.
   5. DVR and DDSD will use creative approaches to secure jobs for Jackson Class Members
      and seek methods or providing competitive employment opportunities (as defined in this
      MOA) through innovative contracts/programs.
   6. Participate in selected team meetings of Jackson Class Members whose teams may not be
      supportive of work and assist individuals to consider other provider options if necessary.
      DVR Supported Employment Coordinator will ideally be provided 8-10 weeks notice,
      but in no event less than 4 weeks notice of these meetings.
   7. Maintain specific liaison staff with statewide and regional responsibility for monitoring
      and implementing this agreement:
          A. Ensure that all liaisons understand their role as facilitators of employment for
              individuals with the most significant disability(ies).
          B. Train appropriate staff, and share relevant information within the liaison’s
              assigned area.
          C. Maintain relationships with DDSD providers in order to achieve the annual
              targeted employment outcomes.

   8. Disseminate this agreement to all relevant DVR staff and facilitate regional discussions in
       conjunction with DDSD, to clarify the purposes, intent, and responsibilities of the two
       agencies in implementing this agreement. An emphasis will be placed on referrals of
       Jackson Class Members with identified employment goals.
   9. Provide information to DDSD as delineated in this agreement.
   10. Set annual targets for employment outcomes in collaboration with DDSD.
   11. Work with DDSD to identify alternative vendors, including new providers who specialize
       in individualized job development and job placement.
   12. Work together with DDSD to target referrals to DVR for individuals currently in
       segregated settings.
   13. Co-sponsor training for key stakeholders on quality employment outcomes, innovative
       approaches, best practices and employer negotiations.
   14. Review cases at the local level and collaborate with DDSD to solve individual and
       systemic issues.

III. Joint responsibilities of DVR and DDSD:
     1. Regional Meetings – DVR Area Liaisons and DDSD Regional Employment Coordinators
         will meet on a quarterly basis at the regional level to address local issues and to review
         outcomes. Other key people (individuals who use services, parents, guardians, advocates,
         case managers, services providers) may be invited, based on the agenda and the necessity



                                              B - 26
      of additional input. Agenda minutes and outcomes from the meeting will be sent to
      Liaisons and Coordinators.
   2. Statewide Meetings – DVR Supported Employment Coordinator, DVR Area Liaisons,
      DDSD Regional Employment Coordinators, and DDSD Supervisors will meet at least
      twice a year at the statewide level to address systems issues, to review outcomes, and to
      alter strategies as necessary to meet targeted outcomes. Other key people (individuals
      who use services, parents, guardians, advocates, case managers, service providers) may
      be invited, based on the agenda and the necessity of additional input.

IV. Targeted Outcome for July, 2005 – July, 2006:
    1. The targeted outcome for FY 06 is DVR receipt of 20 Jackson Class Member referrals
       with 7 job start ups for Jackson Class Members.
    2. Targeted Outcomes for July 1, 2006 – June 30, 2007, will be jointly established by May
       1, 2006. Targeted Outcomes for July 1, 2007 – June 30, 2008 will be jointly established
       by May 1, 2007.

                                       SECTION FIVE
                                     Administering Agency

DVR shall administer Federal Title VI-B time-limited funds. DDSD shall administer funds
designated for supported employment long-term support. No funds shall be transferred between
the two administering agencies.

                                        SECTION SIX
                                    Records and Accounting

DVR and DDSD shall maintain an accurate record of all documents and reports submitted by
contractors, grantees or other fee for service agencies pursuant to the obligations established by
the Agreement. Such records shall be maintained in accordance with generally accepted
accounting principles and state and federal requirements and shall be preserved and made
available to DVR and DDSD, agencies of the State of New Mexico, and/or agencies of the
federal government during the period of this Agreement.

                                       SECTION SEVEN
                                         Modifications

This instrument contains the entire Memorandum of Agreement between the parties and no
statement, promises, or inducements made by either party or agent of either party that is not
contained in this written Agreement shall be valid or binding. This Memorandum of Agreement
may not be enlarged, modified, or altered except in writing signed by the parties and endorsed
herein.

                                        SECTION EIGHT
                                         Choice of Law

This Memorandum of Agreement shall be governed by the laws of the State of New Mexico.


                                              B - 27
                                         SECTION NINE
                                          Confidentiality

Any identifiable personal information regarding DVR and DDSD clients which is provided to
the contractor, sub grantee or other agency shall be used only for purposes which would
significantly improve the quality of life for persons with disabilities through the development of
an effective supported employment program, and shall be governed by the requirements of 34
CFR 361.49 and by Department of Health Policies on HIPAA Privacy.


                                          SECTION TEN
                                            Reporting

DVR shall provide bi-annual cumulative client reports to DDSD which include, but are not
limited to: client identification number, description of types of services, IPE date, employment
outcomes, and dates of services, and the name and location of the client’s supported
employment service provider. DVR and DDSD will exchange information to monitor potential
duplication of funding of providers of supported employment services.

                                       SECTION ELEVEN
                                       Term of Agreement

This Memorandum of Agreement becomes effective when approved by DVR and DDSD and
will continue through June 30, 2008.

                                       SECTION TWELVE
                                          Termination

The performance of this memorandum of agreement is subject to the condition that sufficient
funds are appropriated, authorized, and allocated by the Legislature of the State of New Mexico
and/or by the federal government.

In the event that Federal or State laws are amended or judicially interpreted so as to render the
fulfillment of this agreement on the part of either party unfeasible or impossible, or if the parties
are unable to agree upon modifying amendments which would be needed to enable substantial
continuation of this agreement as a result of such amendments or judicial interpretation, then,
and in that event, either DVR or DDSD shall be discharged from further obligations under the
terms of this agreement, except for the completion of work commenced prior to the date or
termination.




                                               B - 28
In witness thereof, the parties have executed this agreement:

New Mexico Public Education Department,
Division of Vocational Rehabilitation:



____________________________________________                    ___________________
Gary Beene, Assistant Secretary, DVR                                  Date

____________________________________________                    ___________________
Approved for Legal Sufficiency                                        Date

New Mexico Department of Health:


____________________________________________                    ___________________
 Sam Howarth, Director, DDSD                                           Date


____________________________________________                    ___________________
Michelle Lujan Grisham , Secretary                                    Date


____________________________________________                    ___________________
Approved for Legal Sufficiency                                        Date
Assistant General Counsel




                                              B - 29
                     Working Together To Reach Employment Goals

                       For Persons with Developmental Disabilities
                                        Guide #1



                        The Basics of VR/DD Supported Employment
                       for Support Service Brokerage and OVRS Staff




Created by the SPD Staley Implementation Team,
Support Service Brokerage Staff
and
the Office of Vocational Rehabilitation Services
Administrative & Field Staff

Fall 2004




                                           B - 30
                                           Introduction

A Mandate For Partnership

Beginning in 2002, new support services and funds became available through the Staley
Settlement to help individuals with developmental disabilities maintain independence at home
and in their communities. The Staley Settlement represented a renewed opportunity to
strengthen the partnership that brings together time-limited services provided through the Office
of Vocational Rehabilitation Services (OVRS) and long-term support available through Seniors
and People with Disabilities (SPD) and DD local resources to help individuals with
developmental disabilities get and keep a job through supported employment. Although there
had been success in interagency or joint efforts between local Support Service Brokerage
Personal Agents and VR Counselors, the service system lacked a clear model of how to service
providers would best work together.

An Interagency Workgroup was established in late 2003. Members of the workgroup included
Brokerage Directors, Personal Agents, VR Counselors, VR Branch Managers, family members
of people with developmental disabilities, advocates for people with developmental disabilities
as well as representatives from both DHS’ Staley Implementation Team and OVRS’
Administration Unit. Their mandate was to:

• Identify the process that would support effective services and real employment outcomes for
  customers;
• Develop and or identify tools that would increase staff and customer understanding and
  participation in the process.

This diverse membership brought varying levels of understanding of the service systems
involved and varying experiences related to the success of collaboration between systems.
Through honest communication and personal commitment, the workgroup members discovered
that they were united in their belief that employment has great value, builds self-esteem,
encourages self-empowerment and enriches the life of the worker as well as the lives of those
closest to him or her.

The Products of the Workgroup

The VR/DD Workgroup is proud to share with you the following materials designed to increase
understanding and success for all involved in a partnership to achieve competitive employment.

Guide #1    The Basics

Identifies the common values, process, general guidelines and outcomes that are the foundation
of the VR/DD partnership to achieve supported employment for common customers.

Guide #2    The Toolkit

Identifies interagency guidelines and best practice tools for each major stage in the service


                                              B - 31
delivery process.

Customers’ Guide

Information provided in a user friendly manner to help persons with developmental disabilities
and their families understand and make informed choices in the process of getting and keeping a
job and career. You are presently reading Guide #1, The Basics.

A Note on Terminology

Throughout these guides, individuals with developmental disabilities will be referred to as
―customers.‖ The authors acknowledge that service providers outside the brokerage system use
other terms, including client, consumer and participant. Since the term ―customer‖ better reflects
an individual’s right to choose to participate and to engage as a full partner in the process, that
term has been selected for use.

The term ―DD Personnel‖ is used in situations where the policy relates to Brokerage Personal
Agents assisting customers with distinct person centered support service plans and budgets
and/or County DD Services Coordinators assisting customers with an ISP that may include a slot
payment to a designated provider for employment or other services.

Common Values in VR/DD Supported Employment Services

As the workgroup began to formulate goals and share ideas, it became clear that all members
shared a set of common values:

• Persons with significant disabilities can work for real wages in community settings.
• Public agencies can provide leadership in assisting customers in exploring and achieving
  gainful employment that matches their talents and abilities.
• Service access and decision-making should be effective and timely.
• OVRS and SPD (Brokerages and County DD Programs) can work as ―team players‖ for and
  with each individual with developmental disabilities. Everyone brings expertise to the table to
  assist the individual.
• Supported Employment is a means for OVRS and DD (state SPD, county CDDP and local
  Brokerage) to work together to help a customer choose, learn obtain and keep a job/career.
• Customer choice, involvement and responsibility are shared values evident in all phases of
  OVRS and DD service delivery.
• Services are provided with respect for each agency’s rules and regulations and with openness
  to what will work for each individual customer.
• All available resources should be used to achieve employment goals.

Supported Employment Service Delivery Stages

After establishing these values, the group was able to identify and define specific stages in
service delivery, which were common across customers and geographic locations:



                                              B - 32
Stage 1: Employment Screening

A Personal Agent uses Person Centered Plan, VR Eligibility Checklist and other information to
identify potential joint service customers.

Stage 2: VR Application Meeting

The initial meeting between the customer, family, PA and counselor (the Team) to review
supported employment process, timelines and resources. This meeting is expected to end with a
VR file being opened.

Stage 3: Establishing Vocational Goals

The team will identify present interests/goals; if needed they will arrange an Employment PCP or
additional assessment activities to identify career choices.

Stage 4: Supported Employment Planning and Funding Implementation

Team develops joint plan (VR IPE + Brokerage ISP) based on customer choice and potential
barriers. The goals, resources, benchmarks, expected timelines and criteria for handoff from VR
to DD are identified and defined.

Stage 5: Vendor Selection

Based on plan design, consumer choice and interagency consensus, the team will identify
vendor(s) and document projected service hours, expected reporting requirements, designated
benchmarks for outcomes, etc.

Stage 6: Delivering and Monitoring Short Term Supported Employment Services

Vendor will report to team every 3-4 weeks on job development, placement, training to
stabilization and the process of securing necessary ongoing supports.

Stage 7: VR Case Closure: Rehabilitated or Other

For ―Rehabilitated‖ closures, the customer has achieved job stabilization and has maintained
employment in an integrated setting at a competitive wage for at least 90 days (or has a timeline
for attaining a competitive wage in place) and the Brokerage Long Term Support plan has been
placed in VR file. For ―Other than Rehabilitated‖ closures, the VR file is closed and the
Personal Agent, family and customer are aware of the reason for the closure as well as what must
happen before VR can work with the customer again.

Stage 8: Ongoing Employment Support

Occurs through the Individualized Support Plan and is monitored by the Personal Agent.


                                             B - 33
Supported Employment Services Flowchart
                 Stage 1
           Employment Screening

                  Stage 2
               VR Application


                   Stage 3
        Establishing Vocational Goals

                   Stage 4
       Planning & Implementing Funding
          (VR IPE & Brokerage ISP)


                  Stage 5
              Vendor Selection

                   Stage 6
      Delivering & Monitoring Short-term
       Supported Employment Services


                  Stage 7
              VR Case Closure

                   Stage 8
         Providing Ongoing Supports

               B - 34
Supported Employment Service Flowchart

As seen in the graphic on the previous page, there are several stages to the service process that
lead to successful employment in a supported employment setting. A brief overview of each
stage is included here, to serve as a quick reference for OVRS and Brokerage Staff.

Stage 1: Employment Screening

County DD or Brokerage Staff Screening

•   Complete General Person Centered Plan (PCP) to see if individual identifies employment as
    a goal.
    o If the goal is employment in an integrated setting at a competitive wage, proceed with
        flowchart and in partnership with VR.
            An integrated setting is one where workers with disabilities and workers without
            disabilities are employed and interact together.
            Job Coaches and others providing employment supports are not included in the
            definition of ―workers without disabilities‖ for this definition.
            Enclaves cannot be defined as integrated settings.
    o If the goal is sheltered employment or supported employment at sub-minimum wage,
        proceed with planning without VR as a partner
•   PA reviews Essential Worker Characteristics document to ensure the customer is ready to go
    to work.
    o Based on results, PA may provide information about VR services, benefits counseling and
       initial resource analysis.
    o PA offers to attend VR orientation/intake session if customer is interested and available
•   Brokerage staff will work with customer and significant others to complete VR Eligibility
    Checklist to the best of their ability.

Stage 2: VR Application Meeting

Personal Agent contacts OVRS to schedule a meeting with the VR Counselor. This meeting
should include customer, customer’s advocate(s) or family, Personal Agent and OVRS staff.
Discuss the following:

•   Interest in employment
•   Effect of employment on benefits
•   Available plan resources
•   Approximate timelines to employment
•   Customer’s interests, skills, barriers etc.
•   Need for further information or answers to additional questions

If customer decides to move forward with VR, the VR Counselor will open a file.

If customer decides NOT to move forward with VR, the PA/other provider proceeds with

                                              B - 35
alternative planning; VR may be considered in the future.

Stage 3: Establishing Vocational Goals

Working as a team, the customer, counselor and PA will explore possible career choices and
answer three (3) questions:

    • Are any career choices already identified via school and work experience?
    • Do we want additional opportunities for exploration?
    • Do we need further information to establish the customer’s abilities and disability-related
      barriers to employment, confirm the customer’s choice or to identify components of the IPE?

If needed, the team will use the Employment Person Centered Plan (EPCP) as the primary
method for establishing career goals and identifying short- and long-term employment support
needs. Movement to Community-based Work Evaluation will occur only after an Employment
PCP if the team has identified it as necessary.

Employment Person Centered Plan (EPCP)

EPCP is based specifically upon the information to be obtained and questions to be answered.
This activity will be done with all members of the team involved. Findings are the basis of plan
development to be done in Stage 4.

Career Exploration

OVRS counselor will arrange a Community-based Work Evaluation, if one is determined
necessary by the team. Effort should be made to match the assessment to the interests identified
in Employment PCP. The length, intent and information needed at conclusion of the
assessment must be clearly identified prior to initiation of the assessment.

Stage 4: Planning & Implementing Funding (VR IPE & Brokerage ISP)

The team will meet and formalize plans to help the customer get and keep a job. The team will
review benefits and any financial plan commitment, if applicable. The team will also review
how communication will flow and the responsibilities and expectations of all team members. It
is also necessary for the team to set up services, review schedules and timelines.

In both the IPE and ISP documents, the team should be sure to address:

•     When will the team know the goal is reached?
•     Are ALL disabilities and barriers identified and accommodated?
•     How will goals and resources impact plan, vendors etc?
•     How will we secure other resources?
•     How will progress be evaluated?
•     What supportive services may DD fund at the same time?
•     How will we know to move from VR to long-term support?


                                               B - 36
Stage 5: Vendor Selection

Vendor selection may occur at any time in Stage 3, 4, or 5. Selection will be from a pool of
state-approved vendors identified locally by VR and DD. The team may choose to use the same
vendor throughout both the IPE and ISP or to select a series of vendors at each stage, as
appropriate.

The use of one or more vendors will be dependent on three factors:

   Plan design
   Customer informed choice
   VR and DD consensus, since both agencies will generally be funding and evaluating
    services.

If any member of the team feels a change in selected vendor is necessary, the decision to release
or retain vendors will be made in collaboration with the entire team. Customer and family
choice will be honored wherever possible, given legal requirements placed on OVRS and DD
regarding vendor selection.

Define and clarify the performance measures expected from vendor:

   Outcomes
   Written reports
   Number of service hours to be provided per week or month
   Check-in points
   Involvement of the customer in the process

Plan Design

Identify if the supported employment design means that one vendor or job coach will be
involved in short term (job development, training) and long-term support. If the team plans to
use a coworker for long-term support (in either a paid or a natural support format), they must
clearly identify how the vendor will train and prepare the coworker for this role. The job
development design may involve ―job carving,‖ matching specific job tasks to worker abilities.
Supported Self-Employment may be the most appropriate plan design for some customers.

Customer Informed Choice

Whenever possible, the customer should have the chance to interview and choose from a pool of
possible vendors.

Interagency Consensus

The Team will ensure that the chosen vendor understands supported employment
implementation, including changing expectations and rates in transitioning from short term to
long-term supports.


                                              B - 37
Stage 6: Delivering and Monitoring Short Term Supported Employment Services IPE
         Service Delivery

OVRS will pay for agreed upon IPE services. The team will reconvene on an established
schedule. This schedule should include a face-to-face meeting, e-mail, or phone communication
at least every 3-4 weeks to discuss progress based on identified criteria. OVRS staff is
responsible for coordinating progress meetings and ensuring all parties are informed of
progress/issues. If the whole team cannot meet, those who are absent will be provided notes, as
appropriate, in a timely manner.

Securing Employment

The customer will be hired into a paid, community-based job expected to meet job goal criteria.

Job Coaching and/or Training to Stabilization

OVRS will pay for job coaching or training to the point of job stabilization as initially defined in
Stage 4 and refined throughout the plan implementation process.

Long Term Support Plan (Support Services ISP)

The team will identify resources and activities necessary to keep employment following VR case
closure. This document will be placed in both the OVRS and DD files.

Stage 7: VR Case Closure

Rehabilitated

The VR case will be closed as Rehabilitated when the following criteria have been met:

   The customer has been employed for a minimum of 90 days and is earning or working
    toward earning a competitive wage.
   Job stabilization as defined in plan has occurred
   If the customer is working toward a competitive wage, the OVRS Counselor has documented
    when that is expected to be achieved.
   The DD system has completed all action to ensure ongoing supported employment payments
    necessary.

Other than Rehabilitated

The VR case will be closed as Other than Rehabilitated at any point in the process if:

   The customer chooses to terminate OVRS services
   The customer is unable to continue participation in VR services
   The customer moves out of the OVRS service area
   The customer’s disability becomes too severe to allow further participation


                                               B - 38
   The customer does not follow through on medical advice or treatment
   The customer does not cooperate and actively participate in the VR process

Stage 8: Providing Ongoing Supports

Brokerage Staff Responsibilities following OVRS case closure:

   Arrange for or provide services identified in Long term Employment Support Plan (ISP)
   Monitor or assist customer or designated person in monitoring PASS plan or other Work
    Incentive, when applicable
   Assist customer or designated person in monitoring essential wage reporting to Social
    Security
   Review and revise ISP ―supported employment‖ services and/or budget as necessary and
    available
   Utilize OVRS Post Employment Services for one-time disability-related employment needs

General Guidelines for VR/DD Partnership

The following are general guidelines that apply to all joint planning and service delivery.
Additional guidelines specific to each stage in the VR-DD Process are included in Guide #2, the
Supported Employment Toolkit.

1. OVRS and SPD have a common commitment to the gainful employment of persons with
   developmental disabilities who desire paid jobs in a community setting. By October 15, 2004
   Brokerages and Local VR Offices will use the format provided to develop and submit a Local
   Area DD Supported Employment Implementation Plan identifying methods of collaboration.

2. Local Brokerage Directors and OVRS Branch Managers will identify the number of local
   plans needed in a region. If more than one plan is being developed in a region, the date for
   submission may be negotiated.

3. As a part of the Local Area Plan, the Brokerage(s) and local VR Office(s) will create a list of
   preferred vendors based on proven performance for both agencies in the delivery of quality
   supported employment and/or services to persons with developmental disabilities.

4. OVRS and DD personnel are team players and will work together in the development,
   implementation and monitoring of both a time limited VR Individual Plan For Employment
   (IPE) and the long term Individual Support Plan (ISP) necessary to assist customers to get and
   keep a job.

5. OVRS and DD personnel will share copies of each individual’s IPE and ISP in order to ensure
   full understanding of the supported employment plan.

6. The individual will have the opportunity to make informed choices throughout the process of
   development and implementation of the supported employment plan.



                                              B - 39
Informed Choice in VR and Brokerage Services

Over the last 15 years changes in the Rehabilitation Act, Medicaid, IDEA, and the Workforce
Investment Act regulations have been made to support increased customer control and ―informed
choice‖ or ―self determination‖ in the disability field. Although the language may be a little
different, Brokerages and VR are both working to implement informed choice or self-
determination with their clients/customers.

―Self-determination‖ is the philosophy and process by which customers with developmental
disabilities are empowered to gain control in the selection of support services that meet their
needs. Principles of self-determination are:

• Freedom: the ability of a person, together with their family and others important to them, to
  plan a life with necessary supports rather than purchasing a predetermined program
• Authority: the ability of a person (with the help of a support network, if necessary) to control
  a certain sum of resources to purchase support needs
• Autonomy: the arranging of resources and personnel—both formal and informal—that will
  assist the individual to live in a community and enjoy rich affiliation with that community
• Responsibility: the acceptance of a valued role in the community through competitive
  employment, organizational affiliation, personal development, and caring for others, as well as
  accountability for spending of public dollars in ways that are life enhancing for persons with
  developmental disabilities

Things to Note

• All people indicate choice--sometimes with words, sometimes with actions (which others may
  help to interpret).
• Informed Choice or Self-determination means new learning, attitudes and relationships for
  everyone!
• There is a recognized tension between VR’s traditional focus on the individual and the DD
  system’s recognition of a role for the family as reporters, advice givers, guides and an
  essential part of the ―team.‖

Informed Choice/Self Determination: Do You Know It When You See It?

The following is a partial list of some of the ways that a VR Counselor and Personal Agent could
help to make choice and self-determination a part of everything that they do with a customer.
See if you can add to this list!

During Employment Screening and Application

• Determine level of personal involvement of customer, family members and significant others
• Identify the types of information and decisions the customer desires to take the lead with
  when considering employment




                                              B - 40
In the Identification of an Employment Goal

• Complete an Employment Person Centered Plan
• Perform a Community-based Assessment to find what types of employment will build on
  individual strengths
• Value families and non-paid supporters as participants in the process
• Consider job carving or job creation as placement approaches, if appropriate
• Explore supported self-employment, if appropriate

During Plan Development
• Ensure the plan design reflects the needs of the individual
  o The pacing of service
  o The schedule (week, day, etc.) of service delivery
  o Level of provider effort
  o Level of customer effort
• Make sure the definition of Job Stabilization (which initiates VR case closure) includes:
  o Employee/client satisfaction
  o Other measures determined by customer
• Confirm that the amount of resources each person receives is individualized to their unique
  and specific needs

In Provider Selection and Monitoring

• Encourage Individual to interview potential providers and make final selection

Next Steps

The information in this manual gives you an overview of the process you and your teammates
will follow to assist customers with developmental disabilities to obtain and maintain
employment. A manual written specifically for customers and their families and advocates is
also available. By using the partner manuals and their tools, you will be able to assist your
customers in a more efficient, effective and successful manner.

Included with these manuals is a disk with a PowerPoint presentation that provides a general
overview of the teamwork process. Written in partnership by OVRS and SPD Staley
Implementation Team staff, it provides an engaging and easy to understand picture of how the
process should work. It is intended for use in training OVRS, County DD and Support Service
Brokerage staff members; you are encouraged to view it with your local partners.

Local area plans will be made and reviewed as needed. These plans will outline how Support
Service Brokerages and OVRS branch offices will collaborate on staff training, service delivery
and evaluation. By implementing these plans, local partners will create even closer connections
and smoother processes than presently exist.

If you have questions about the information in this manual or the Toolkit, contact OVRS
Administration or the SPD Staley Implementation Team. Staff there will be happy to assist you


                                             B - 41
to get the answers you need.

Appendices

       What Are the Staley Settlement and Brokerage Support Services?
       What is Vocational Rehabilitation?
       What is Supported Employment?
       Local Area Contact Lists




                                           B - 42
             What Are the Staley Settlement and Brokerage Support Services?

What is the Settlement?

Staley vs. Kitzhaber was a lawsuit brought by 6 families of adults with developmental
disabilities who had been waiting for services and supports for many years. The lawsuit
Settlement Agreement resulted in a plan for additional support services for approximately 5300
eligible adults over a multi-year period. The Staley Implementation Team is the unit of staff
within DHS’ Seniors and People with Disabilities (SPD) group that is responsible for the
development of support services in line with the Agreement. Support Services for
Adults is one portion of the system of services for people with developmental disabilities where
services are provided in a manner that is the most self-determined. Support Services do not
include 24-hour care.

Who is Eligible and How Do They Get Access?

All eligible adults (aged 18+) who live at home in communities around Oregon must receive
support services by June 30, 2005. There is a State-established Order of Enrollment to ensure
fairness and equity. The County Community Mental Health Program (CMHP) manages the
enrollment process and a designated number of people per county enter each month. As of
August 2004, there are 2979 customers receiving Support Services.

What Does A Person Get Through Staley/Support Services?

The most important outcome is a plan, focused on assisting the individual to stay in the
community, which is developed based on self-determination. By utilizing the self-determination
model, customers have greater freedom, control, choice, and opportunity based on their needs.
Customers also have assistance from an individual called a Personal Agent (PA) to help them
plan for their needs and secure resources to meet those needs. Personal Agents work for an
organization called a Brokerage. Customers also receive funds they can guide and use to help
achieve the plan. Funds and supports available add to the resources already available in the
community. Customers can use available funds for an array of supports designed to keep them
stable at home and engaged in their community.

What Does a Brokerage Do?

A ―Support Service Brokerage‖ or "Brokerage" is an entity that performs certain functions in the
planning and implementation of Support Services for adults with developmental disabilities.
Based on the principles of self-determination and the practice of Person Centered Planning
(PCP), Brokerages are designed to:

• Assist customers with developmental disabilities to determine their needs, plan Support
  Services in response to these needs, and develop individualized budgets based on available
  resources.
• Assist customers with developmental disabilities to find and use the resources necessary to
  implement planned Support Services.


                                             B - 43
• Assist customers with developmental disabilities in ensuring the effective implementation of
  their plans over time, and help make adjustments to the plan or plan goals as necessary.
• Provide information, education and technical assistance for customers with developmental
  disabilities in order to help facilitate effective plan implementation.
• Act as a general fiscal intermediary in the receipt and accounting of certain funds on behalf of
  an individual in addition to making payment with the authorization of the individual, and
  accounting for certain support plan costs.
• Assist customers with developmental disabilities in fulfilling their roles and obligations as
  employers of personal caregivers when plans call for such arrangements.
• Facilitate development and expansion of community resources.
• Assist customers with developmental disabilities in monitoring of the quality of their
  supports.

How Do the Brokerages Work With OVRS & Other DHS Programs?

When an individual wants a job, the PA and OVRS staff will work together based on a local
interagency agreement. Brokerages also work actively with SPD’s Disability Service Offices
(DSO) staff on issues related to benefits, health care, etc.

Brokerages may also work actively with SDA partners in completing their responsibilities related
to:

•   Surveying and identifying community resources
•   Building essential community capacity to meet customer needs
•   General community education to support inclusion and integration of people with disabilities
•   Customer education in monitoring service quality




                                              B - 44
                              What Is Vocational Rehabilitation?

Oregon's Office of Vocational Rehabilitation Services (OVRS) assists Oregonians with
disabilities to achieve and maintain employment and independence. OVRS is a state- and
federally-funded program that works in partnership with the community and with business to
develop employment opportunities for people who have disabilities. Vocational Rehabilitation
(VR) programs are custom-designed for each individual. Services include (but are not limited
to):

•   Vocational Counseling and Guidance
•   Evaluation
•   Physical Restoration
•   Vocational and other training services
•   Information and referral
•   Job Development and Job Search Assistance

Customers work directly with a VR Counselor, who has specialized training in providing
counseling services to people with disabilities. VR is an eligibility-based program; in order to be
eligible, individuals must have at least one documented disability that causes barriers to their
getting or keeping a job. Customers receiving Social Security (SSI/SSDI) benefits are
automatically presumed to be eligible for VR services if they are seeking employment in an
integrated setting and require VR services. VR staff work with those customers to gather needed
documentation for eligibility while moving ahead immediately with vocational planning. In
some cases, a customer initially presumed eligible may be determined ineligible for VR services
if there is clear and convincing evidence that the severity of the consumer’s disability or
disabilities make him or her incapable of a successful VR employment outcome, despite VR
services.

Following eligibility determination, the VR Counselor works with the individual and, if
appropriate, members of his or her support network to identify a specific job goal and to outline
the services and supports needed to achieve that goal. This information is compiled into the
Individualized Employment Plan (IPE), which is the roadmap the team will follow. The IPE is
not a contract, but a living tool to assist the individual to achieve his or her work goals:
throughout the plan implementation period, services may be added or deleted as needed,
on an individual basis. Once the individual has found a job, stabilized in that job and has worked
a minimum of 90 days, the VR case file may be closed and the individual may be considered
―Rehabilitated.‖




                                              B - 45
                              What is Supported Employment?

Supported Employment is an employment option that facilitates competitive work in integrated
work settings for individuals with the most severe disabilities for whom competitive employment
has not traditionally occurred. Because of the nature and severity of their disability, these
individuals need ongoing support services in order to perform their jobs. Supported employment
provides assistance such as job coaches, transportation, assistive technology, specialized job
training and individually tailored supervision.

Generally, this means the customer obtains a paid position in an integrated employment setting
with other employees with and without disabilities. The individual will receive a competitive
wage or will be working toward a competitive wage and prior to beginning employment,
ongoing support needs and sources of support will be identified and planned for.




                                             B - 46
                           Local Area Contact List

Region                OVRS Branch Offices                    Brokerages
Metro OVRS District      Central Portland                   Inclusion Inc.
                             John Doe                May Nelson, Acting Executive
                         1234 SE 5th Ave                       Director
                        Portland, OR 97202                 5432 SE 1st Ave
                      John.Doe@state.or.us               Portland, OR 97202
                          503-731-3200                  May@inclusioninc.org
                       503-731-3201 (TTY)                 503-232-2289 x25
                       503-731-3202 (Fax)                503-235-6914 (Fax)




                                   B - 47

								
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