Social integration, inclusion, and community participation are among the stated goals of policies that address services used by people with intellectual and developmental disabilities (IDD), but how individuals spend their days continues to challenge decision-makers and service providers. Texas policymakers must examine meaningful day activities not only within the current day habilitation structure, but also in the context of community based non-work opportunities.
Day habilitation is defined as a facility-based service provided in a group setting during weekday work hours. Although individuals are not required to include habilitation on their service plans, Medicaid community-based waiver participants typically do include day habilitation. Services vary, but may include recreational activity, specialized therapy, and life skills training. It is widely accepted that day habilitation programs require remediation. Many are segregated, involve repetitive tasks rather than skill building activities or employment goals, and some are co-located with sheltered workshops where workers are paid below minimum wage.
HCBS Settings Rule
As a result, day habilitation services are being reformed around the nation to raise standards. These changes are outlined in the Medicaid Home and Community Based Services (HCBS) Settings Rule released by the Centers for Medicare and Medicaid Services (CMS) in 2014. The HCBS Settings Rule presents an opportunity for innovative solutions to emerge so that people with disabilities can have increased community engagement and exercise greater control over their own lives.
The HCBS Settings Rule addresses the quality of HCBS long term services and supports and provides additional protections to people that receive services.
In order to be in compliance with the HCBS settings rule services must be:
- Integrated in the greater community, to the same degree of access as individuals not receiving HCBS, including opportunities to:
Seek employment and work in competitive, integrated settings, and
Engage in community life.
- Selected by the individual from a variety of setting options, including non-disability specific settings.
Service settings presumed to be isolating include day habilitation facilities that:
Serve only people with disabilities,
Aim to meet all the recipients needs for habilitation services, and
Impede integration in the larger community.
HCBS Compliance Deadline Approaching
Day habilitation programs in Texas are widely regarded as out of compliance with the HCBS Settings Rule. States were given five years to bring their systems into compliance.
Senate Bill 204 (2015) would have required a stakeholder workgroup to study and make recommendations to improve day habilitation, but the bill failed to pass. In the absence of statutory direction to convene a new stakeholder workgroup to address day habilitation, the Department of Aging and Disability Services is looking to the already established IDD System Reform Advisory Committee Employment and Day Habilitation Subcommittee in response to continued recommendations by advocates to include stakeholders in regulatory and programmatic reform..
The Health and Human Services Commission (HHSC) and Department of Aging and Disability Services are also hosting stakeholder forums around the state to provide information on how the HCBS Settings Rule will impact community based services including day habilitation. Sessions will be held in the following locations on the following dates:
- San Antonio, October 22
- Lubbock, October 27
- El Paso, October 29
- Harlingen, November 3
- Fort Worth, November 6
- Tyler, November 9
More details for the meetings are available: hhsc.state.tx.us/medicaid/hcbs/index.shtml
A Time for Action
The HCBS Settings Rule will require a redesign for how day habilitation services are provided in order to bring the state into federal compliance. Waiver participants, providers and service coordinators will likely need to re-imagine meaningful day activities on an individualized basis. This will include discussions of individual choice and person directed practices, provider rates to adequately support waiver participants, defining outcomes and collecting data to monitor accountability at a state level, and creating a realistic and working transition plan with high expectations to achieve true community integration.
Texas is not the only state struggling with how to modernize day habilitation in terms of how individuals participate and the outcomes to be achieved. Best practices to consider include Oregon state agencies who strengthened collaboration by entering into a Memorandum of Understanding to support transitioning students with disabilities to enter the workforce. They were able to leverage new funding as well as sequence existing funding strategies to support their efforts. The MOU also addressed reporting by streamlining agency data collection and making it available to stakeholders. Other states, like Vermont and New Hampshire, have also reduced duplication of effort by implementing effective strategies and partnerships to efficiently coordinate resources. Texas Employment First Task Force has begun discussions about system improvements, but without sustained agency commitment and effort, some are concerned that their work could stall.
Recommended Actions for System Improvement
The following are recommended actions for system improvement:
Modify reimbursement methodologies because the current allocation supports segregated day options and contradicts prevailing service philosophy regarding integration;
Designate employment supports as the primary method of funding state-financed day services;
Initiate day activity plans before high school graduation by offering comprehensive transition programs that give students credit for working in the community within multiple work settings to explore interests and skills;
Create basic skills certificate to indicate a person’s competitive employment skills and certify qualifications for persons without a high school equivalency diploma;
Prohibit the co-location of sheltered workshops and day habilitation facilities; and
Expect that the system offers employment as the first and preferred option provided to working age adults who receive public benefits.
Role of Community-based Non-work
Public policy should focus on eliminating practices that contribute to barriers to the full participation of people with disabilities. By promoting opportunities for people to be engaged in social spaces within their communities, inclusion and productivity can be experienced – not just taught. Successful integration policies must foster meaningful social relationships and build community capacity for systems change. Community-based non-work can offer an opportunity to accomplish just this.
Community-based non-work (CBNW) supports individualization, choice, integration, and independence to individuals in search of meaningful day activities, with the right expectations set. Outcomes must be clear in state policy and provider practice for CBNW to improve the quality of life for people with disabilities. The following are recommended policy expectations for CBNW:
- Expect employment as follows:
Allow CBNW to supplement employment rather than substitute it.
Affirm that if people with disabilities are to be treated as equals in society, then to some extent they should have equal obligations as well-which includes an obligation to contribute to society through working.
Expect individual choice and life planning
Emphasize person-centered planning and acknowledge CBNW as simply one aspect of a person’s plan to achieve his or her goals and desires in life.
Expect that group activities are a matter of choice, not convenience
Manage program quality by creating CBNW as a separate category of service with clear goals and minimum standards for person directed outcomes.
Expect integration and community membership
Incentivize time spent in integrated spaces that connect people and facilitate quality relationships with a variety of community members without disabilities.
Expect the development of strong models of CBNW
Involve family members, friends, self-advocacy and other peer groups, places of employment, churches, and other community spaces in setting and achieving goals for individualization, integration, choice, and independence.