Data, research, and feedback from people with disabilities and other stakeholders consistently show that the new residential and day services of waiver redesign, as well as opportunities for competitive integrated employment, are fraught with provider capacity issues, individual access and choice issues, and general confusion about the new services and how they operate.

As of September 2020, new residential service authorizations (Independent Living Supports, Supported Living, and Shared Living) still only accounted for about three percent of all residential service authorizations under all DD waivers (Virginia Department of Behavioral Health & Developmental Services, November 2020). Providers have been slow to offer these services and few individuals have benefited from them.

The Commonwealth still lags behind integrated day and employment goals set through the Department of Justice (DOJ) Settlement Agreement. Review of the data and agency reports shows that there are significant gaps in addressing barriers to employment and community engagement, particularly for people with more support needs.

VBPD’s research found that, to work as designed, the new services require strong self-advocacy, tailored approaches appropriate to individual needs, and more providers able to adapt to new ways of delivering supports.

Assessed Residential Services and Supports

Supported living has been an available service in the Community Living and Family and Individual Supports waivers since 2016. Yet, as of October 2020, there were only 20 providers of this service. Eleven of the twenty service areas had no providers. Providers report that the rate model for this service does not cover their costs to provide Supported Living services. There remains general confusion among Medicaid enrollees, Support Coordinators, and potential service providers about Supported Living, including questions as to how it operates, who can be supported using this service, and licensing requirements.

Independent Living Supports is the only service available in the Building Independence (BI) waiver that is not available in other waivers. In essence, this means that the state is administering and operating an entire 1915(c) waiver for one service. The level of effort and resources required to operate a waiver are significant. Operating an entire 1915(c) waiver for one service is not a prudent use of valuable resources. In addition, because personal assistance was not included as a BI waiver service, the BI waiver meets the needs of very few individuals on the Priority One waitlist. Many people on the Priority One waitlist who are offered a BI waiver slot turn it down and continue to wait for a Community Living (CL) or Family and Individual Supports (FIS) waiver slot. If there are no individuals on the Priority One waitlist willing to accept a BI waiver slot, a regional Waiver Slot Assignment Committee session is held to assign the BI waiver slot(s) to individuals meeting criteria from Priority Two and then Priority Three waitlists. This practice is not consistent with assigning waiver slots based on priority of need.

Shared Living has been an available service in all three DD waivers since 2016. Yet, as of April 2020, there was one provider enrolled to be the administrative provider of shared living services. Providers report that the requirements and expectations of the administrative provider generate risk and liability concerns. In addition, providers report a lack of service structure that facilitates and supports an individual to successfully transition in a person-centered and individualized manner to their own home or apartment. These concerns, coupled with an inadequate rate to cover the administrative provider costs to provide this service, create a disincentive for providers to enroll as an administrative provider of Shared Living.

Additionally, there is confusion among individuals and families, Support Coordinators, and potential service providers about many aspects of the Shared Living service, including allowable roommates and the availability of additional services and supports to meet an individual’s needs.

Assistive Technology, Environmental Modifications and Electronic Home-Based Supports are services that provide individuals with greater autonomy and independence. In peer-to-peer interviews, self-advocates shared information about innovative uses of technologies and supports that add to their independence, sense of security, and overall well-being. However, these services are often not used to their maximum benefit due to the complexities of service authorization and access, lack of provider capacity, and in some cases, service funding caps that do not cover the cost of a specific technology or home modification. These services are sometimes provided by a private provider that can reduce the actual benefit to the individual through provider fees. As individuals and their families know what items will best meet their needs, allowing a fee-charging “broker" reduces the individual’s ability to obtain needed Assistive Technology, Environmental Modifications and Electronic Home-Based Supports.

Assessed Employment and Day Services

Supported Employment services in Virginia need innovation and transformation to modernize the culture and expectations of employment for individuals on the DD waivers. Interviewed individuals reported that the success of their employment depended greatly on the creativity of their job coaches. Others reported that they were essentially turned away from employment services because of their needs for support in the workplace. Many support coordinators, families, and others within the system assume that employment is not a viable choice for individuals who need a higher level of support in finding and maintaining employment. This assumption is also evident in the lack of creativity in helping individuals customize a job that benefits both the employee and employer. Change must address the root causes of inconsistency in the experience of individuals and families as well as the practices that create inconsistent results.

System-wide factors contribute the inconsistency in quality of service. First, the current employment service model is based on an hourly rate model that does not incentivize job placement and retention. Additionally, Department of Behavioral Health and Developmental Services data and reports of the Independent Reviewer show that barriers to employment are often not meaningfully addressed. Further, little effort is made to educate individuals about employment after they indicate they are not interested in working during ISP meetings.

There is limited understanding of supported employment policy, practice, and expectations across the DD waiver services system and among critical partners. This knowledge gap has a negative impact on people with disabilities who are interested in employment. There is also a knowledge gap on the impact of paid employment on a person’s Medicaid and Social Security benefits. This lack of understanding is sometimes fueled by misinformation about options regarding working, how to begin employment, and the impact employment on an individual’s state and federal benefits.

Waiver funds cannot be used to support sheltered workshops in Virginia. Yet, DBHDS has reported that some individuals participated in sheltered workshops using DD waiver funding. DBHDS attributes this count to individuals attending a waiver-funded day program that also offers sheltered workshop activities. Even when waiver funds do not directly support sheltered workshops, it raises the question of whether waiver-funded day programs financially benefit sheltered workshops.

Community Engagement, Community Guide, Community Coaching and Workplace Assistance.  While Community Engagement waiver services authorizations have increased 38 percent since 2017, growth has remained relatively level since 2018. Individuals on all three waivers are eligible both for Group Day and Community Engagement, yet Community Engagement continues to lag far behind Group Day in terms of the percentage of people on the waivers using that service in all regions. Providers indicate interest in Community Engagement but find the rates are insufficient for the service. For safety and best practice, many providers require at least two staff members to accompany individuals in the community. Providers report the rate does not support a 2:3 staffing ratio, and thus providers do not feel they can offer the service safely or to individuals who may need 1:1 support for community activities.

Overall service authorizations for the integrated day services increased 1.4 percent from June 2019 to June 2020. The number of providers for Workplace Assistance, Community Guide and Community Coaching remains small and unevenly distributed across the state. For individuals to benefit from these services, there must be providers with the capacity to serve them. Many individuals would qualify for a mix of Community Engagement, Group Day and Community Coaching services, yet providers report that the paperwork required for each service discourages them from providing a mix of services to the individual.