path to employment training - oacbdd.org
TRANSCRIPT
Path to Employment Creative and Legal Ways to
Authorize HCBS Employment Services
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Lori Stanfa, Medicaid Services Coordinator Kim D. Linkinhoker, Associate Director Panel Members
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Who are all the players? Why this is important History of Supported Employment Services using HCBS waivers Path to Employment – Braiding and Blending Services
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Agenda Continued
• Dirty Details and Urban Myths • Local Panels • Table Work – Getting people Jobs in your community
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Our beliefs
• We really believe in Community First • Broad audience – won’t meet everyone’s needs • Debunk some myths • Not give you intimate details on how to provide the specific services • A general understanding of the process of assisting individuals to get a job • Continued conversation and focus on training • Probably won’t be able to take a lot of questions
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Our beliefs
• We can do better! • Tomorrow the shops won’t close • Tomorrow we will still have segregated programs • WE HAVE NOT BEEN DOING BAD THINGS FOR THE PAST 40 YEARS IN OUR SHELTERED WORKSHOPS>>>>>WE HAVE LEARNED NEW WAYS TO SUPPORT PEOPLE
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Stump the presenters
Email burning questions to: [email protected]
We will review and answer on our website
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WHO ARE THE PLAYERS?
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Ohio Department of Developmental Disabilities
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BVR BSVI BDD
Cabinet Level Agency -
Federal Level
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Map
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Service Providers
County Boards as providers
Private providers
Providers of Vocational rehabilitation services
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Employers!
Service organizations in the community!
School Districts!
Other Stakeholders
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WHY THIS DISCUSSION IS IMPORTANT
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Talking about Integrated Employment for 30 years It’s the right thing to do
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What does it all mean?
States need to show measurable progress
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We know the obstacles • Transportation • Parent and individual bias • Legacy Programs • Lack of jobs • Lack of quality service providers • Shifting from a segregated to integrated service delivery model • Loss of benefits • Employer reluctance • People work part time in community and part time receive adult day supports • VR Relationship strained • Lack of providers both VR and HCBS • Family beliefs
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We have opportunity • Employment FIRST initiative • Although cumbersome we do have waiver services to support employment • Strong Advocacy movement • Focus on Transition of Youth from school • People want a life in their community
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SOME OBSERVATIONS
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Waiting on the State of Ohio to do Something
Employment First – Executive Order now codified
Will transform the state system
Will provide some opportunities for local boards
It is more than Employment First it is about connecting individuals to their community
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From 2011 HCBS Waiver data 7% of individuals are enrolled in Supported Employment
93 % are receiving Adult Day Supports and Vocational Habilitation
No wage data
No benefit information
Ohio’s Use of Sheltered Workshops
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Fiscal Data Medicaid Data from department reflects 2245 individuals have SE –community as authorized service. Only a 34% utilization at this point in August.
Increased rates has not dramatically shifted use of Supported Employment – Community – 500 individual increase from June of 2012.
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Employment Data • Many boards have difficulty providing accurate numbers of individuals in community employment
• No one individual responsible for data collection
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Individual Service Plans
What do individual plans say about employment?
How are current services leading to a job?
Are services provided based upon an outcome of community/employment first principles?
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Little Use of Work Incentives
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A Continuum of Services Is Not Evidenced Based Practice
Sheltered work
Mobile crew
Enclave with industry
Leads to a job
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Free Choice of Provider • Misinterpretation of Free Choice of Provider Rule
• Services provided should be based upon the individual
• Individuals of a working age should have vocational services provided that lead to integrated employment
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Steps to Resolution:
What You Can Do Tomorrow
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Leadership Board
Administration
Staff
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Strategic Planning and Agency Policy
• Develop or review the agency’s current policies on community employment. Is this based upon reality? • Develop or review your strategic plan and make employment related services a primary focus for board provided/contracted services. • Strategic plan will most likely become a requirement in the future through the Administration Rule changes and Employment First Rule. • Includes action steps to resolve obstacles pointed out earlier.
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What does your Strategic Plan say about these Obstacles?
Transportation Parent and individual bias Legacy Programs Lack of jobs Lack of quality service providers Shifting from a segregated to integrated service delivery model Loss of benefits Employer reluctance People work part time in community and part time receive adult day supports
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Requirements for Strategic Plans
Objectives Defined
Measurable
Timetable Specific
Reasonable
Reasonable projection of numbers
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SET A BENCHMARK
Have a start point number and set performance expectations and metrics for reaching the goal
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Funding Commitment Defined
Part of strategic/annual plan
Condition funding on achievement of goals
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Individual Assessment and Planning
Ensure that ISPs are written that are based upon functional assessment data
Person-Centered planning process
ISPs include integrated employment goals including activities leading to a job
Community Based assessments
Discovery
Interest inventories
Job tryouts
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Individual Service Plans
Free choice of provider excuse
Build support plans to success
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Make ONE person responsible in the for tracking employment data...
Data needs to be in one location
Can’t be searching plans to find data
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Keep It Simple The state is developing standardized definitions, but do not wait.
Deal with duplicative counts (individuals in integrated and adult day programs).
Provide more data than “working in the community”.
Find and include the people who were placed successfully in the past 20 years and make sure they are still employed and COUNTED.
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Keep It Simple Working in community employment setting earning minimum wage or above
Wage
Hours
Benefits – check off
Working in an industry based enclave
Working in a mobile work crew
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System Development
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Educate the Community
SIMPLIFY THE LANGUAGE WE USE
Speakers Bureau
Business Partners
News articles on successes
Service Clubs
Business Clubs
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Coordination Develop MOUs with local school districts on Transition services
Close the front door
Million dollar decision
Partnerships with Veterans, Behavioral health
DODD
RSC/OOD
Chamber of Commerce
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The ‘88’ Help someone get a job, that at first, look appears impossible and non-realistic.
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Work Incentives Every county has one person on Medicaid Buy-In
One PASS Plan written
One successful IRWE
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Five Guiding Elements for employment systems change (Paul H. Wehman, Journal of Vocational Rehabilition,2011)
• Support self-determination and person centered planning for people with disabilities • Focus on community integrated job outcomes • Expand relationships with business • Systems change is mission driven • Align dollars with mission
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THE TOOLS AVAILABLE UNDER A HCBS WAIVER
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Available to individuals enrolled on: Level One Individual Options Self Waiver
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Supported Employment
What it is:
Intensive, ongoing supports that enable participants, for whom competitive employment at or above the minimum wage is unlikely absent the provisions of supports, and who because of their disabilities need supports, to perform in a regular work setting. Supported Employment does not include sheltered work or other similar types of vocational services furnished in specialized facilities.
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Supported Employment - Community
means supported employment services provided in an integrated community work setting where individuals enrolled in a waiver and persons without disabilities are employed to perform the same or similar work tasks.
OAC - 5123:2-9-15
What it is SIMPLYHELPING PEOPLE GET AND
KEEP A JOB
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History of Supported Employment using HCBS waivers
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History
• Supported Employment has been a waiver service in Ohio since 1992 but was not authorized in most counties until last several years. • Changes in 2008 separated SE-community from SE-enclave definitions and rates.
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History
• Rate increase in 2012 has increased utilization of SE-C and provides new opportunities for county boards and providers to partner. • AAI budgets have not increased to support the increased rate…need to address.
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History
• Uneven access to OOD Services through BVR/BSVI • Required a form to show ineligibility for VR services in the past
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Current stats
• 2245 individuals are authorized to receive SE-C on PAWS • 68 counties have authorized providers to bill • 34% average utilization statewide…privates billing far more than county boards
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The Process and Common Practice
What does an SSA need to know to authorize services that demonstrates a path to employment
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Services • Vocational assessment • Job development and placement • Job training/coaching • Ongoing job support • Worksite accessibility • Training in self-determination • self-employment
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ELIGIBILITY
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Adult Array
VOC HAB AND ADULT DAY SUPPORT: No longer eligible for educational services
• For Adult Day Supports/Voc Hab for Self Waiver Recipients
• Justification why the services are more appropriate than supported employment-enclave and/or integrated employment.
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Adult Array
VOC HAB • Optimal outcome is integrated employment; occur over a defined period of time; employment goals be in ISP • Not otherwise available from OOD (VR)
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Supported Employment - Community
• Not otherwise available from OOD (VR) • Services cannot be services available under IEP
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Integrated Employment
• Not otherwise available from OOD (VR) • EXCEPTION: Could be in school under SELF waiver and receive integrated employment. Services cannot be services available under IEP
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VOCATIONAL ASSESSMENT
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Community and Workplace Support Model
Determine individuals needs and preferences Brainstorm potential options Assess job and community supports Identify individual choices Develop strategies for accessing supports Evaluate support effectiveness Arrange provision for on-going monitoring
Darlene Unger, Wendy Parent, Karen Gibson, Kelly Kane-Johnston, & John Kregel
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Vocational Assessment
• Must incorporate assistive technology • Occur in environments that resemble actual voc. training or employment environments • Must produce outcomes that contribute to ongoing development, planning and implementation of next steps • Methods must be varied and include a sequence of activities that sample an individual’s behavior and skills over time • Data must be verified by more than one method and by more than one person • Reasonable accommodation • Data must be interpreted to individual and their families
Source: National Secondary Transition Technical Assistance Center University
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All Services are based upon Individual assessment and Person-Centered Planning
• Ensure that ISPs are written that are based upon assessment data • ISPs include integrated employment goals
• Community Based or situational assessments • Discovery • Interest inventories • Job tryouts
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Expectations have changed
• Services currently reflected in ISPs include “on-task” behavior • Service plans should include services that are leading to employment
• Job-tryouts • Job club • Job shadowing • Interest inventories
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General “Discovery” Processes
• Meeting with Family and individual • Community Tour • Compile inventory of local businesses • Talk with support Staff • Advocates • Observe in their environment • Go with them on an activity
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Discovery
• Review history • Compile information into a profile • Share profile • Not in a sheltered workshop
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Situational assessment
• Job type preference
• Motivation and interest
• Socialization
• Use of technology
• Stamina
• Advancement
• Training strategies needed to
deploy for individual to
succeed?
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Benefits Analysis
• PASS
• IRWE
• Ticket to Work
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JOB DEVELOPMENT AND PLACEMENT
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5123:2-9-15/16: Job Development
• Developing a resume that identifies the individual’s job-related and/or relevant vocational experiences. • Training and assisting the individual to develop job seeking skills. • Targeting jobs on behalf of the individual that are available in the individual’s work location of choice.
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• Assisting the individual to find jobs that are well matched to his or her employment goals. • Developing job opportunities on behalf of the individual through direct and indirect promotional strategies and relationship-building with employers. • Conducting worksite analysis, including customizing jobs. • Increasing potential employers’ awareness of available incentives that could result from employment of the individual”.
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• Individual placement • Mobile crew or enclave • Customized Employment • Self-Employment
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JOB COACHING
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Job/training/coaching
• Systematic plan of instruction • Social integration • Generic transportation services • Problem solving • Transition from prior vocational or educational assessment
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Payment Points or performance indicators/Benchmarks
• 4 week retention • 10 week retention • Stabilization
How far will the money go? What portion of budget should be authorized for each element.
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WORKSITE ACCESSIBILITY
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• Reasonable worksite accommodations • Time spent assuring the provision of these accommodations
• Job-tryouts • Job club • Job shadowing • Interest inventories
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ONGOING SUPPORTS
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• Use of Natural Supports • Role of service
• Monitoring as needed • Ensuring individual is working to employers expectation
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• Following-up with the employer and/or the individual at the frequency required • Assisting the individual to use natural supports and generic community resources • Providing training • Hygiene • Work Skills • Social skills
• Self-medication
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Transportation Options under an HCBS Waiver
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(a) Billing for the provision of non-medical transportation is limited to those times when an individual is transported to, from, and/or between sites where adult day support, integrated employment, supported employment-community, supported employment-enclave, and/or vocational habilitation are provided to the individual.
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(d)Nothing in this rule shall be interpreted to prohibit a provider of homemaker/personal care from transporting an individual to access adult day support, supported employment-community, supported employment-enclave, and/or vocational habilitation and billing for homemaker/personal care and transportation in accordance with rules 5123:2-9-30 and 5123:2-9-24 of the Administrative Code.
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INTEGRATED EMPLOYMENT
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Integrated Employment under SELF Waiver
• Rule Requires that when adult day support and/or vocational habilitation are identified in the individual service plan as the service or services to be provided, the individual service plan shall include a justification as to why these services are more appropriate than supported employment-enclave and/or integrated employment. • Services are similar to SE-C but more general • Allows for independent provider with a negotiated rate • Has two services
• Initial supports • Retention supports
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Individual Budgets in County
County CODB category 5 A and A1= $9840 B=$17,760 C=29,580
Transportation=$9,365
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So, what can a budget buy?
A - Annual budget $9960= 235 hours SE-C B- Annual budget $17,940=423 hours SE-C C- Annual budget $29,880=706 hours SE-C
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SE-C Rates
CODB 15 min unit
Hourly Total Annual Hours Available A-C
Independent 5 6.57 25.24 389 - 1172
Agency 5 10.47 41.88 235 - 706
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Integrated Employment Rates – Initial Supports
Budget CODB
15 min unit
Hourly Total Annual Hours Available A-C
Independent Initial Supports
5 NA Minimum wage to 33.99
289 - 870
Agency Initial Supports
5 NA 54.21 181 - 545
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Integrated Employment Rates – Retention
Budget CODB
15 min unit
Hourly Total Annual Hours Available A-C
Independent Retention
5 NA Minimum wage to 27.48
358 - 1076
Agency Retention
5 NA 43.83 224 - 675
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Budgets
• County boards and providers need tools to use to see exactly what budgets can buy.
• In 2008, training focused on FCOP and staying within budgets
• In 2012, SE-C rates increased but budgets did not. • In 2013, we are having a different, serious
conversation about investing in people with jobs…
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Budgets
• So what can we do? • Administrative review- the intent was for
“exceptions” in the AAI. Not intended for everyone to get a job…slippery slope.
• We should redo the AAI in the job site to determine if the supervision needs are different enough to change the score and group.
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Recommendations
• Providers should have an conversation with county board regarding subsidizing budgets for SE-C…this should take place at an administrative level, not at every ISP meeting! Discuss under what circumstance and what process will be used to add local dollars to budgets to help buy individuals a job and a life?
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MYTHS AND TRUTHS
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Myths and Truths
• Myth- Skill development is a requirement for individuals receiving HPC services on IO and Level 1. • Truth- Voc Hab rule requires services that are designed to teach and reinforce habilitation and skills.
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Myths and Truths
• Myth- HPC services are prohibited when an individual is working on a job site in the community. • Truth- This is not expressly prohibited in a rule, however the team agrees it is necessary, services may be authorized. • Time limited • Personal care • Stabilization
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Myths and Truths
• Myth- NMT is only available when an individual in SE-C is actively receiving job coaching services. • Truth- NMT is available as long as the individual is receiving a follow along service through SE-C. (i.e. 1 per month) They are in a Supported Employment worksite
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Myths and Truths
• Myth- An individual must be enrolled in the county board adult program and attend prior to waiver enrollment for refinancing purposes. • Truth- Individuals that apply to be enrolled in any adult services may enroll as a priority on a waiver.
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Myths and Truths
• Myth- Assessments/Discovery must take place at the certified ADS voc hab center to bill waivers. • Truth- Community assessments outside of the facility are best practice in voc hab and SE-C.
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Myths and Truths
• Myth- Transitional youth can receive SE or voc hab waiver services. • Truth- CMS prohibits waiver funding to pay for special education and related services in an IEP that the school districts are responsible for. Individuals are not eligible until they finish school.
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Myths and Truths
Myth: Individuals who enroll on waivers are entitled to free choice of service type for adult day services. Truth: Individuals on waivers are entitled to free choice of providers for services that are based upon assessed needs.
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Myths and Truths
• Myth- SE-C services are not available when RSC is has an active case open for an individual. • Truth- Services that are unavailable thru RSC may be funded by waivers. These may include job club, social skills training, etc.
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Myths and Truths
• Myth- There is a form that RSC must “sign off” to verify unavailability of funds. • Truth- The SSA needs to document in ISP and/or case notes that the services is not otherwise available.
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Different Paths to Employment
• Some do not use RSC or have access • Some only use SE-C for follow along • Some have a clear statement and understanding of various service providers scope of services
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PATH 1 -USING SE-C / VR FUNDS
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Referral to VR
Who Does this SSA or Provider Authorized in plan Person assigned VR counselor VRP-3 VRP-3 Bridges State Counselor – BVR DODD/OOD partnership counselor
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Waiver Service and VR Services (CONCURRENT)
SE-C RSC
Rec./leisure Assessment
Access to community resources Job development
Training in Self-determination Job Coaching
SSA services through TCM Benefits Analysis
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PATH 2 – VOC. HAB
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Using VOC HAB
Referral made to VR. Services not currently available
Use infamous VOC HAB service
5123:2-9-14 (B)(19)(b)(vii)
Developing and implementing a plan to assist the individual to transition from his or her vocational habilitation setting to supported and/or competitive employment, emphasizing the use of natural supports.
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PATH 3 – USING SE-C
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Using SE-C only
• No RSC case is opened • Waiting lists may exist • Case closed
• Full array of SE-C services
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Services • Vocational assessment • Job development and placement • Job training/coaching • Ongoing job support • Worksite accessibility • Training in self-determination • self-employment
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PATH 4 – TRANSITIONAL YOUTH
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Transitional Youth
• ITP at age 14 • What is role of School? • Front Door to services • Not through VOC HAB • RSC • WAIVER
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Transitional Youth
• Million dollar decision
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Authorizations
• How to Authorize Assessment • How to authorize job development
• How much is needed • What type of reports should you expect • What is the span?
• How to authorize job coaching with a movement to fading
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Benchmarks and metrics in budgeting
Cost of assessment- 10% of budget Oklahoma 15% of budget Massachusetts Placement- 15% of budget in Oklahoma 32% of budget in Massachusetts
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Benchmarks and metrics in budgeting
4 week retention- 15% of budget in Oklahoma, 20% of budget for 10 week
retention 14 week retention in Massachusetts- 25% of the budget
Stabilization- 20% of budget in Oklahoma 25% of budget in Massachusetts
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So, what do you do?
• Discussions with the individual and their team should include reasonable expectations on hours that will be needed for each activity.
• Use some metrics or benchmarks to authorize each specific service area and if possible, leave a little cushion for follow up of course…
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Table Top Exercises
6 Scenarios distributed around the room One person serve as a scribe One person willing to share with room There is missing information in the scenarios – make it up and describe what you made up Must use a mix of providers and supports in each example
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Thank you for coming
Stay tuned for more information OACB Annual Convention – Dec. 4-6