Promoting Integrated Employment Outcomes for Individuals with ID/DD: The Wisconsin Approach

1. Promoting Integrated Employment Outcomes for Individuals with ID/DD:The Wisconsin Approach National Council on Disability Regional Earnings Forum October 26th, 2010 Detroit, MI

2. Wisconsin Panel Members • John Reiser, Director, Office for Independence and Employment, Wisconsin Department of Health Services • Charlene Dwyer, Administrator, Wisconsin Division of Vocational Rehabilitation • Lisa Mills, Consultant, Wisconsin Medicaid Infrastructure Grant, Employment and Long-Term Care initiative • Carole Stuebe, Executive Director, Portal Inc., Grafton, WI

3. Wisconsin’s Environment for Medicaid and Long-Term Care System Change Wisconsin Center for Delivery Systems Development (1998-2004) • The State Medicaid Agency’s “Think Tank” for long-term care redesign • Created to address increasing LTC costs, consumer dissatisfaction with services and wait lists • Also given charge to improve employment outcomes for Medicaid recipients with disabilities, including HCBS participants • Developed and implemented “Family Care” model of managed care for people with DD, PD and Frail Elders • Developed and implemented Medicaid buy-in program for workers with disabilities • Advanced service innovations, including Work Incentive Benefits Counseling

4. Family Care • Began with five county pilot in 2000 • One system serving people with developmental disabilities, physical disabilities, and elderly • 2005 evaluation led to legislative support for statewide implementation • 75% of state now under managed care • Self-directed supports waiver offered as another option

5. Family Care • 9,336 individuals with ID/DD in Family Care or SDS option • Entitlement created: ends waiting lists for community services • Outcome driven service authorizations • Reduced per-person spending expected as the result of more cost-effective supports • Increased flexibility on how supports can be provided and who can provide them

6. 2006-07: A Hard Look in the Employment Outcomes Mirror • Most people with disabilities served by the long-term care system are unemployed or employed in non-integrated settings, making sub-minimum wages. • Just 25% of people with developmental disabilities in managed care involved in integrated employment (including crews/enclaves). [2006] • Just 5% of people with physical disabilities in managed care involved in integrated employment. [2006] • 9,416 individuals with disabilities in sheltered workshops making sub-minimum wage, with 35% earning <$1.00 [2005]. • Facility-based employment “quick fix” for people with disabilities coming off waiting lists

7. The Managed Care and Employment Task Force (MCETF) • Created to design a “blueprint” for improved employment outcomes and services in Family Care • Members appointed by Administrator for the Division of Long-Term Care. • Chaired by Deputy Administrator of the Division. • 28 highly respected members, including wide range of stakeholders • Seven issue committees, involving over 100 other contributors • 15 month process • Listening sessions held June, 2008 • Final report submitted July, 2008. • 84 recommendations accepted by Department Secretary in December, 2008. Implementation is on-going.

8. January, 2009 • The Division of Long-Term Care adopted a strategic priority to promote and support integrated employment outcomes among people with disabilities eligible for, or receiving, Medicaid funded services. • Includes individuals receiving long-term care services • Outcome measure for long-term care system: Number of Family Care and SDS waiver participants with integrated employment goals included in their long-term care plans.

9. Key Recommendations for People with ID/DD • The Department should collaborate with DVR on policy guidance for DVR counselors and MCO care management teams in order to ensure DVR services are available to: -Individuals in work centers/sheltered facilities; -Individuals in group employment (e.g. enclaves) -Individuals receiving day services who express an interest in competitive, integrated employment. • The policy guidelines should be covered in the joint agency training and technical assistance efforts.

10. Key Recommendations for People with ID/DD (continued) • The Department should update the service definition of prevocational services to reflect the definition and standards used in the Community Integration Program (CIP) and to further encourage best practices, including the provision of services that offer people the chance to learn skills directly related to achieving their individually identified employment goals. Prevocational services should enhance what is currently available through DVR, and should not be based on a readiness model. For prevocational service providers that offer paid work opportunities incidental to the delivery of prevocational services, the following standards should be incorporated into the service definition: • Adopting a downtime policy • Adopting OSHA health and safety standards • Adopting minimum staffing ratios • Prohibiting unpaid contract work or engaging in training that involves doing unpaid contract work

11. Key Recommendations forPeople with ID/DD (continued) • Policy governing employment services should clarify that a Family Care enrollee can be referred to DVR or to MCO-funded supported employment services without prior participation in prevocational services. • The Department should consider developing rigorous criteria that would apply for new admissions to prevocational services in work centers/sheltered workshops while honoring individual informed choice.

12. Revising Prevocational Service Definition • Family Care waivers due for renewal in fall of 2009. • Revised definitions for employment services included in renewal application • Process began with consulting MCOs and reviewing the updated CMS Technical Guide • MCETF recommendations combined with CMS guidance resulted in revised pre-voc definition

13. CMS Guidance Regarding Sheltered Work • “Waiver funding is not available for the provision of vocational services (e.g., sheltered work performed in a facility) where individuals are supervised in producing goods or performing services under contract to third parties.” (p. 132) • Day Habilitation Services and Supports Guidance: “Day habilitation may not provide for the payment of services that are vocational in nature (e.g. sheltered work).” (p. 153) • Supported Employment Guidance: “Supported employment does not include sheltered work or other similar types of vocational services furnished in specialized facilities.” (p. 156)

14. Revised Prevocational Service Definition • Service should develop general, non-job-task-specific strengths and skills that contribute to employability in integrated, community settings. • Outcome of service is expected to be integrated, employment on at least a part-time basis • People may participate in paid work as part of prevocational service delivery but this is not the intended outcome of the service

15. Revised Prevocational Service Definition • Members who receive prevocational services during some days or parts of days may also receive supported employment, educational, or day services at other times • Participation in prevocational services is not a required pre-requisite for supported employment services provided under the waiver • Prevocational services may be provided in a variety of community locations including but not limited to work centers/sheltered workshops

16. Revised Prevocational Service Definition • Only activities that contribute to the member's work experience, work skills, or work-related knowledge can be included in prevocational services • Prevocational services may be provided to supplement, but may not duplicate services provided as part of an approved Individualized Employment Plan (IPE) funded under the Rehabilitation Act of 1973, as amended, or under an approved Individualized Education Plan (IEP) under the Individuals with Disabilities Education Act (IDEA)

17. Technical Guidelines • Describe in detail how Dept expects revised service definition will be implemented in practice • On-line training on Technical Guidelines released by Dept; open access for all stakeholders; required for care managers • Decision tree tool and sample six month progress and status report also created

18. Technical Guidelines • All prevocational service participants should be making reasonable and continued progress toward at least part-time participation in integrated employment • Pre-voc provider expected to facilitate that progress and connect people with DVR at appropriate time • Everyone is capable of integrated employment with the right job match and supports in place

19. Reasonable and Continued Progress SERVICE PROCESS STEPS: • Identify and address / overcome any concerns or hesitations with regard to integrated employment • Preliminary identification of preferences and conditions related to integrated employment, including non-negotiables • Action steps toward securing integrated employment (including referral to DVR)

20. New vs. Current Prevocational Service Participant • For new entrants, prevocational services in a work center/sheltered workshop cannot be authorized unless an individual has a goal of at least part-time integrated employment. • For new entrants unsure about whether they want to pursue integrated employment, community-based prevocational services may be authorized to assist the individual to make an informed choice. • If new entrants are totally unwilling to explore integrated employment options, pre-voc will not be authorized but group SE will be offered.

21. New vs. Current Prevocational Service Participant • For current pre-voc participants, reasonable and continued progress toward transition to at least part-time integrated employment is expected • A good faith effort by the pre-voc provider over a reasonable period of time is expected – otherwise IDT expected to consider change in provider • If individual/guardian still opposed to part-time integrated employment, pre-voc can continue but would need to include some community-based pre-voc activities

22. Supports for CRPs • Rebalancing grants and technical assistance -Modeled after T-TAP initiative -Customized employment training • Training to inform development of community-based prevocational service models

23. Anticipated Impact on Vocational Rehabilitation Services • Increased referrals to DVR of individuals needing • Community-based assessments • Customized employment placements • Supported employment services (currently @ 12%) • Long term employment supports • Need for a statewide inter-agency service provision agreement supported by: • technical assistance guidance • training for all partners and service provision staff on collaborative, cooperative service provision

24. A Customized Employment Pilot DVR wanted to explore Customized Employment • Worked with System Partners and local Service Providers to develop a pilot • Pilot was conducted in 4 of 11 Workforce Development Areas to gather data and promising practices • 30 Common customers enrolled from a combination of general, current facility referrals and facility diversion projects • Original pilot was for 12 months now extended 6 months

25. Creating a common understanding of the VR “employment outcome standard” • The VR employment outcome standard is more stringent than the MA waiver community employment long term support standard which allows for placements in work enclaves. • There was confusion among our partners about what constituted an “integrated” employment setting that would satisfy the VR standard • DVR decided to develop a White Paper to describe an employment outcome in terms of: • 1. The intent of the Rehabilitation Act • 2. The Act’s federal regulations • 3. Wisconsin VR policy

26. The White Paper Development Process White Paper Development, Reviewed and Feedback collected: • DVR’s Senior Leadership team • DVR Policy Analysts and DVR Managers • The WI DVR Policy Academy • Community Rehabilitation Programs • RSA staff provided review and technical assistance

27. Employment Outcomes – VR Requirements Must meet the three primary characteristics as outlined in the Rehabilitation Act: 1. Competitive Wage 2. Integrated Setting 3. Consistent with an individual’s strengths, resources, priorities, concerns, abilities, capabilities, interests, & informed choice.

28. Employment Outcome Decision Matrix STOP Not integrated Is the employment in the integrated labor market and a setting typically found in the community? NO YES Does the individual with a disability have the same opportunity to interact with non-disabled individuals that non-disabled individuals in the same or similar jobs interact with other persons? “Other persons” include co-workers, the general public, customers, and vendors, but not those providing services to the individual or a supervisor. STOP Not integrated NO YES Is the individual compensated at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals who are not disabled? STOP Not competitive NO YES EMPLOYMENT OUTCOME

29. Transition and Adult Service Interagency Agreement • Developed and agreed to by: • The Department of Public Instruction (Youth) • The Department of Health Services (Adults) • The Department of Workforce Development and DVR (Youth and Adults) • 2010 Interagency Agreement is expanded from the 2007 Youth-based agreement • Focuses on: • Students with disabilities transitioning from high school and adults with disabilities • Collaboratively and cooperatively providing services to achieve integrated competitive employment.

30. Transition and Adult Service Interagency Agreement • Purpose: • Fulfills mandates found in the IDEA and Rehabilitation Acts, and the Wisconsin Department of Health Services Medicaid waiver requirements; • Defines interagency relationships and common policies and procedures; • Creates common understanding at the systemic as well as the service delivery level; and • Establishes collaborative efforts regarding improvement of employment outcomes for individuals with disabilities.

31. Transition and Adult Service Interagency Agreement • Agreement Includes: • Overview of transitioning to employment • Agency commitments and priorities • Terms and resolution of conflict.

32. Transition and Adult Service Interagency Agreement • Technical Assistance Guides (TAG) • Support and put into practice the Interagency Agreement • Designed for all stakeholders in the process- consumer, parents, DVR Staff, Teachers, Care Managers, etc. • Two TAGS • Transition • Adult Services

33. Impact on Prevocational Service Providers:Threat, Challenge or Opportunity? Key Questions • Skill training, Production or Employment? • Short term or long term option? • Continuation of 14c sub-minimum wage? • Future availability of work? • Choice? Real Choice? Informed Choice?

34. Impact on Prevocational Service Providers:Threat, Challenge or Opportunity? Key Questions • Seemingly predictable/sustainable service revenues along with agency-directed services? OR Less predictable revenues and self-directed/externally-directed service delivery? • Service/supports desired by future transitioning students? • Beneficial learning and experience options: how; where; for how long; all of it work related? • Service rates versus costs? Staffing ratio/structure?

35. Prevocational Services: The Portal Way • Less dependency on subcontract work • More emphasis on community, employment learning sessions and confidence building opportunities • Short term, ancillary and safety net service option • Employment awareness and preparation opportunities (not job readiness) • Holistic and community experience model • Informed choice and self advocacy • Starting with the person

36. Impact on Portal as a Service Provider • Referral and Service Policy for Working Age Adults (18 - 55 years) • Position paper • Employment Definition- “real, regular and ordinary” • Employment as a first and encouraged option • Transitional services for students 16-18 years for school to work planning and preparation • Service Plan outcomes, next actions and documented progress • Production focus to holistic learning opportunities and community/work experiences

37. Impact on Portal as a Service Provider • Informed choice, self advocacy • Rebranding our service to a process towards an outcome, not a model. • Staff, family and community awareness/education • Restructure staff • Service rates-level of service and outcomes • Quality Indicators and Customer Service

38. Seizing Opportunity for Change • The time has come • Challenge the status quo… “Is happy enough?” • Sense of urgency and opportunity • Stay true • Celebrate and celebrate often • Education and mentoring through DHS: MIG grant activities and opportunities • New Connections-Renewed Connections

39. Participating in DHS/MIG Rebalancing Initiative • Individuals transitioning from prevocational services to at least part-time integrated employment • Students transitioning from school to integrated work • Building community connections • Information sharing • Education and Mentoring • Recognition • $$$ to plant the seeds to initiate the change

40. Umbrella of Employment Services and Strategies • Principle of the ordinary way • Discovery Profile • Portfolio Development • Informational Interviewing • Customizing Employment • 3 themes and list of 20 potential employers • Coaching for ordinary/regular supports • Proactive employment follow up, mentoring, consulting and solution finding • Relationship building at the front end not the back end

41. Going Forward • Team structure • Quality Indicators (for performance and outcomes) • Funding and rate setting that incorporates: 1) actual service components (direct staff, program management, staff mileage, staff training, administrative and general expenses) 2) enhanced levels of service/support for some individuals 3) performance or outcomes 4) stabilization (hours worked of employee not staff support hours)

42. Stay Focused • “Obstacles are those frightful things you see when you take your eyes off your goal.” -Henry Ford • “Your desire for success should be greater than your fear of failure.” -Bill Cosby

43. For Electronic Version of Presentation and Handouts Please contact John Reiser: John.Reiser@dhs.wisconsin.gov 608-266-3063

44. Presenter Contact Information Charlene Dwyer, Wisconsin DVR 608 261 2126 charlene.dwyer@dwd.wisconsin.gov Carol Stuebe, Portal Inc. 262 377 4410 cstuebe@portalindustries.org Lisa Mills 608 225 4326 lisa.mills@dhs.wisconsin.gov