Employment and Community Inclusion Services for People with Developmental Disabilities

The 2017 operating budget (ESSB 5883) directed the Joint Legislative Audit and Review Committee (JLARC) to review employment and community inclusionFormerly called community access services offered through the Department of Social and Health Services (DSHS).

Employment and community inclusion services are part of a larger system of services

Within DSHS, the Developmental Disabilities Administration (DDA) manages a variety of services for eligible adults with developmental disabilities. These adults live in the community, not institutions. Most services are funded through a combination of state general fund and federal Medicaid dollars. Other services include paid caregiving, skilled nursing, behavioral health, psychiatric services, community guides, and transportation.

Within DDA, the Employment and Day Services program manages employment and community inclusion services. Both of these services are administered through contracts with county developmental disability authorities. Most counties contract with private companies to deliver services to clients.

Clients must follow a four-step process to receive employment or community inclusion services through DDA

To become a client, a person must have a qualifying disability and meet financial requirements. While clients may enter the process at different times (e.g., as youth or adults) and receive different services, there are four basic steps to the process. More detail is in Appendix A.

1. Application: Individuals who are residents of Washington, have a qualifying developmental disability that began before age 18, and have evidence of substantial limitations are eligible to be DDA clients. Becoming a client of DDA does not guarantee access to paid services such as employment and community inclusion.
2. Assessment:

   Levels of support needs for employment services

   Low: Independent in the community and requires little job support. Medium: Independent in the community some of the time and requires moderate job support. High: Requires support in the community at all times to maintain health and safety and requires significant job support.

   Clients must contact DDA to request services. After that, a DDA case manager schedules an assessment. DDA uses an assessment to determine a client's service needs, the level of support required to meet those needs, and how many service hours the client may receive. Clients with higher support needs can be authorized to receive more service hours.
3. Waiver application: DDA offers employment or community inclusion services as part of a package of services called "waivers." Waivers are tailored to specific populations. They are called waivers because the state waives certain requirements of federal Medicaid law, and clients waive their right to receive services in an institution. Most clients that receive DDA-funded employment and community inclusion services are on a waiver.
   • Waiver participation is limited and based on factors such as funding, priority populations, and unmet needs. JLARC staff analysis found that between fiscal years 2015-18, DDA denied 13% of applications to the Basic Plus waiver due to funding. Basic Plus is the most common waiver for clients in employment and community inclusion services.
4. Service plan: A case manager works with the client to develop a "Person Centered Service Plan," which documents all services the client may receive, as well as their support level and service hours. The client selects a provider for each authorized service.

Clients must use services or receive monthly monitoring to remain eligible

In order to maintain eligibility for waiver services, clients must use at least one service under the waiver every month or receive temporary monthly monitoring from a DDA case manager. Clients also must participate in both a financial review and DDA’s assessment each year.

❮ Previous    Next ❯   

The Developmental Disabilities Administration (DDA) manages services for eligible adults with developmental disabilities. Employment and community inclusion are two services clients may choose. Both are managed by DDA's Employment and Day Services program.

Individual supported employment is intended to help clients attain gainful employment

The goal of individual supported employment services is for clients to achieve and maintain integrated, gainful employment in their community. DDA defines these terms as follows:

• Integrated means that the service occurs in a regular community setting. The setting is not designed specifically for individuals with disabilities, and the majority of people in the setting do not have disabilities.
• Gainful employment means employment that reflects achievement of or progress towards a living wage. A living wage means that a client earns enough income to meet or exceed their living expenses. Clients in individual supported employment receive minimum wage or more.

DDA policy: Supported employment shall be the first option for clients

In 2006, DDA created the "Working Age Adult" policy, establishing supported employment as the "primary use of employment and day program funds" for clients age 21-62. The policy de-emphasized other day service options.

This policy is consistent with a national movement known as "employment first," which calls for public agencies to prioritize competitive integrated employment as the first use of funds for employment and day programs.

State law requires clients younger than 62 to participate in employment services for nine consecutive months before they can enroll in community inclusion, unless they apply for and receive an exception.

DDA uses contractual and financial incentives that prioritize individual supported employment

DDA's policy and agreements with counties create contractual and financial incentives that prioritize individual supported employment over other employment and community inclusion services.

• DDA's Working Age Adult Policy requires counties to ensure that supported employment services are available. It is unclear how DDA ensures sufficient provider capacity for community inclusion services.
• While counties set actual hourly provider rates, DDA sets the maximum rate the counties can pay their providers for each service. The highest hourly provider rate is for individual supported employment services.
• Case managers can approve additional individual supported employment service hours beyond the base hours determined in a client's assessment when there is an identified employment need. These extra hours can double the number of monthly service hours a client is eligible to receive. The extra hours and additional payments create another incentive for providers to prioritize individual supported employment.

Exhibit 2.1: Providers of individual supported employment receive the highest hourly rates

Source: County-DDA program agreements and JLARC staff analysis of fiscal year 2018 DDA billing data.

DDA's prioritization has led to more clients and increased spending for individual supported employment compared to other employment services and community inclusion

The contractual and financial incentives have supported the growth in individual supported employment over the last decade.

• In fiscal year 2008, individual supported employment accounted for 41% (3,663) of employment and day program clients and 38% ($17.9m) of expenditures.
• In fiscal year 2018, it accounted for 75% (6,975) of all clients and 82% of total service expenditures ($54.7m).
• See Appendix B for interactive client and spending data.

Exhibit 2.2: Clients served and expenditures increased for individual supported employment (fiscal years 2008-2018)

Note: Other employment services includes group supported, prevocational and another service called person-to-person that DDA eliminated in fiscal year 2012.
Source: JLARC staff analysis of DDA client and fiscal data.

Prevocational services: DDA will end these services by March 2019

DDA stopped enrolling new prevocational clients in September 2015 and will phase out the service entirely by March 2019. It cites two reasons:

1. In January 2014, the Centers for Medicare and Medicaid Services (CMS) issued a new rule meant to ensure that persons with developmental disabilities “have full access to and benefits of community living and the opportunity to receive services in the most integrated setting appropriate.” All states were required to review service settings and submit a plan in order to maintain federal funding. DDA decided that Washington's prevocational services providers could not meet the integrated settings standard. It developed a plan to phase out the service, and CMS approved it.
2. DDA determined that clients were staying in prevocational services for long periods, instead of moving to integrated employment settings. JLARC staff analysis found that clients who left prevocational services between fiscal years 2008 through 2015 spent an average of 5.5 years in the service. Eleven percent had received the service for more than 10 years.

JLARC staff analysis shows that, of the 163 people who left prevocational services in fiscal years 2016 and 2017, 134 (82%) enrolled in another employment or community inclusion service within one year.

Exhibit 2.3: 82% of clients who left prevocational services enrolled in a different service

Source: JLARC staff analysis of DDA client data, fiscal years 2016-17. Left services includes 20 clients who did not enroll in other DDA services but remained on the "no paid services list" and 9 who became ineligible for DDA services. Eligibility is explained on tab 1.

Group supported employment: Number of providers is declining

The number of group supported employment providers has declined annually since fiscal year 2013. The declining number of providers has coincided with similar declines in service expenditures and number of clients.

DDA does not monitor provider capacity but rather contracts that responsibility to counties.

Exhibit 2.4: Group supported employment provider participation, clients, and spending have declined since fiscal year 2013

	Fiscal Year 2013	Fiscal Year 2018
Number of group supported employment providers	52	31
Counties with a provider	27	20
Percent of employment and day service clients	14%	7%
Percent of employment and day service spending	13%	6%

Source: JLARC staff analysis of DDA client service data.

Providers reported that another challenge for group supported employment is increased federal and local restrictions on paying workers less than minimum wage. Some local governments have banned the practice. New federal regulations require providers to certify that each client has been offered the option of individual supported employment services, where employers must pay minimum wage. Group supported employment providers believe restrictions have led to higher compliance costs and limited the places providers can operate.

❮ Previous    Next ❯   

Compared to other states, Washington has the highest percent of clients enrolled in integrated employment services

The Washington State Developmental Disabilities Administration (DDA) helps clients get jobs through employment services. Integrated employment services includes both individual supported employment and group supported employment.

In 2016, the University of Massachusetts Institute for Community Inclusion published a report that showed that 87 percent of clients in Washington received employment services in an integrated setting. The next closest state, Oklahoma, served 61 percent of clients in integrated employment services. Not all clients who receive employment services have a job.

Exhibit 3.1: Compared to states with similar policies and to the national average, Washington has the highest percent of employment and day program clients enrolled in integrated employment services

Source: Institute for Community Inclusion, 2016 State Data Report. Policy similarity determined by the National Association of State Directors of Developmental Disabilities Services.

73% of clients in individual supported employment are employed, and 10% earn a living wage

DDA's objective for individual supported employment services is to help clients achieve gainful employment. That is, they should be able to earn a living wage — enough money to meet or exceed their living expenses.

JLARC staff analyzed DDA data for the 6,975 clients enrolled in individual supported employment during fiscal year 2018. We found that:

• 5,110 clients (73%) were employed. They worked an average of 47 hours per month and earned an average wage of $583 per month. Unemployed clients may be in the job development phase.
• 675 clients (10%) earned more than the federal poverty level ($12,140 per year for a single person). Those below the poverty line include clients who were unemployed.
• Earnings vary by support needs.DDA clients are separated into three categories based upon level of support needed. Clients with lower support needs tend to earn more wages.
• See Appendix B for interactive client employment and wage data.

Exhibit 3.2: 10% of clients in individual supported employment earn more than the federal poverty level, but this varies by support needs

Source: JLARC staff analysis of fiscal year 2018 DDA client wage information. DDA does not identify a specific amount for a living wage, so JLARC staff used the federal poverty level as a benchmark.

Clients with high support needs work fewer hours and are more likely to be unemployed

JLARC staff analysis of data for the clients in individual supported employment during fiscal year 2018 found that:

• 44% of clients with high support needs were unemployed. This is double the rate for clients with medium support needs and five times the rate for clients with low support needs.
• Clients with high support needs who were employed worked 21 hours per month on average. This is less than half the average hours for clients with medium support needs, and a quarter of the hours for the clients with low support needs.
• 99% of clients with high support needs earned less than the federal poverty level.

Exhibit 3.3: Unemployment rate and average hours worked each month varies by level of support need

Source: JLARC staff analysis of fiscal year 2018 DDA client wage data.

Clients who also use Division of Vocational Rehabilitation employment services are more likely to get a job

Clients may be directed to another division within DSHS — the Division of Vocational Rehabilitation (DVR) — for short-term employment services. Federal law prohibits individuals from receiving employment services from both programs at the same time.

• DVR operates under different federal laws and with different federal funding than DDA.
• DVR pays providers based on milestones that clients achieve, while DDA pays an hourly rate.
• DVR services are available to people with all types of disabilities, while DDA is limited to developmental disabilities.
• DVR can fund more intensive supports early in a job and pay for supports such as work uniforms or minor workplace modifications. DDA cannot pay for these supports.

JLARC staff analysis found that 80% of DDA clients that use DVR-funded services attain employment, compared to 73% of all DDA clients. In most cases, DDA requires that unemployed clients apply for DVR-funded services first. If a client secures a job, DVR funding continues until the person is determined to be stable in their job, generally 90 days. After that, the client transitions to DDA for longer term services. Clients who do not find a job can transition to DDA services if they are eligible.

❮ Previous    Next ❯   

The Washington State Developmental Disabilities Administration (DDA) articulates six quality of life benefits that its employment and community inclusion services are intended to achieve.

DDA does not directly measure quality of life outcomes. As a result, it is not possible to know whether or not its services are achieving these outcomes.

Industry experts recommend measuring quality of life outcomes

JLARC staff contracted with the Research and Training Center on Outcome Measurement (RTC/OM) at the University of Minnesota's Institute on Community Integration. RTC/OM is a federally-funded project that aims to improve outcome measurement of services for persons with developmental disabilities.

RTC/OM staff state that "quality of life measurement is essential to understanding the relationship between the services provided and the outcomes." The staff note that, in the absence of systematic measurement, there is only an untested assumption that services are improving the clients' quality of life. They point out that administrative data (e.g., provider billing data, employment data) is not a substitute for asking clients and their families direct questions about their quality of life.

RTC/OM staff acknowledge that measuring quality of life is a complex task. However, they assert that measures can be identified that allow the state to make more informed decisions about policy, resource allocation, and programs. RTC/OM staff identified a variety of established approaches that have been tested through research. In addition, RTC/OM is developing its own set of measures focused on employment and community inclusion. For example, its measures would ask clients whether they agree or disagree with statements such as "you feel accepted by your coworkers" and "you find the activities you engage in enjoyable." RTC/OM's full report is available in Appendix D.

DDA tracks some indicators, but it does not directly measure quality of life outcomes

DDA has systems to track administrative data such as hours and wages. While the data can serve as indicators, it is limited and does not directly measure quality of life outcomes.

Exhibit 4.1: Indicators in DDA's administrative data are limited for quality of life outcomes

Source: DDA administrative systems.

In November 2017, DDA began to collect some information in individual case files on clients' employment goals, vocational strengths, additional support needed to be successful in employment, and preferred work hours. However, DDA does not currently use this information for system-wide outcome analysis or program management.

DDA participates in the National Core Indicators (NCI) survey, which is an effort by public developmental disabilities agencies in 39 states to measure and track client well-being. DDA submits the information to a national association but does not use information gathered in the surveys to shape policies or programs.

Benefit-cost analysis would be limited because it cannot currently account for quality of life measures

In response to the Legislature's request for information on the costs and benefits of services, JLARC staff contracted with the Washington State Institute for Public Policy (WSIPP). WSIPP specializes in social service benefit-cost analyses.

WSIPP noted that it could not attach a monetary value to quality of life outcomes, so they cannot be used in a benefit-cost analysis. Since quality of life benefits are important intended outcomes of DDA's services, a benefit-cost analysis would have limited value for investigating or comparing the benefits of employment and community inclusion services.

WSIPP searched for studies that could allow researchers to estimate the effect of employment and community inclusion programs in Washington. It identified a small number of national multi-site studies that analyzed the monetary benefits of individual supported employment programs. However, it cautions that the results may not be generalizable to Washington because the mix of programs in the studies do not reflect the programs currently available in the State. WSIPP did not find any high-quality studies that evaluate the effects of community inclusion, prevocational, or group supported employment services.

The Legislative Auditor recommends that DDA implement a system to measure quality of life outcomes for its clients in employment and community inclusion services

DDA should plan and implement a system to measure whether employment and community inclusion clients are achieving the quality of life outcomes described in WAC 388-825-056.

The Department of Social and Health Services concurs with this recommendation. You can find additional information on the Recommendations tab.

❮ Previous    Next ❯   

Community inclusion is the primary alternative to employment services

Community inclusion is an individualized service, with activities designed around a client's interests. It is intended to support clients in making connections to people who are not paid to be with them. The service is usually delivered on a one staff-to-one client ratio, although in some cases, two or three clients with similar interests and goals may participate with a single staff member.

In 2012, the Legislature directed the Washington State Developmental Disabilities Administration (DDA) to "strengthen and improve" the community inclusion program. Based on that direction and stakeholder feedback, DDA has taken some improvement steps. For example, it now offers training and technical assistance to providers and has a frequently asked questions document for clients interested in accessing the service.

Statute requires DDA to offer clients the choice to transition from employment to community inclusion after nine months

By law, clients cannot receive community inclusion services at the same time as employment services. Until 2012, DDA’s rule was that employment services were the only option for clients age 21-62 years.

In 2012, the Legislature mandated that:

Clients age twenty-one and older who are receiving employment services must be offered the choice to transition to a community [inclusion] program after nine months of enrollment in an employment program.

RCW 71A.12.290

Employment and community inclusion clients can also access community guide. Community guide is a short-term service meant to assist with specific, focused goals, such as finding a new place to live or attending a festival. DDA intends for the service to supplement individual supported employment. At present, it is smaller than community inclusion. In fiscal year 2018, it served 430 clients and cost $680,000.

DDA policy may limit transitions to community inclusion. The agency does not track whether clients are offered the choice.

A balance must be struck between pursuing an employment first policy and also meeting statutory requirements to inform clients they can switch to community inclusion. At times, DDA policy and practice limit the circumstances in which a client could switch to community inclusion services.

• While statute requires only a nine month waiting period, DDA policy limits authorization to clients who “haven’t found a job and decide not to continue looking for work.” This policy potentially excludes clients who have a job but wish to switch to community inclusion.
• In interviews with JLARC staff, some DDA case managers said they initiate discussions about community inclusion, while others said the client has to request it without prompting.
• DDA policy allows case managers to offer clients extra service hours and other support to help them stay in individual supported employment services.

DDA does not track or verify whether individual clients have been offered the choice to switch to community inclusion services after participating in employment services for nine months.

In 2017, DDA eased the process for approving exceptions to the 9-month requirement and began tracking data about exemptions

As required by state law, DDA allows clients to ask for an exception to the requirement that they use supported employment services for nine months. In 2017, DDA changed the process and notified case managers. All requests are now reviewed and approved by the head of the Employment and Day Services program. DDA tracks data about requests, approvals, and denials. It has denied one out of 17 requests since it began tracking.

Stakeholders reported a lack of awareness and confusion about the community inclusion program, as well as concerns about service restrictions

JLARC staff interviewed stakeholders from 10 counties, including persons with disabilities, their families, DDA case managers, provider staff, and county staff.

Awareness: While some stakeholders reported that community inclusion allowed DDA clients to grow and connect with their community, others were unaware of community inclusion as an option. Some of those who were unaware had looked for work for more than nine months.

Confusion: JLARC staff encountered different views among stakeholders about what activities (e.g., bowling, gardening) were permissible, the purpose of the program (e.g., pathway to employment, retirement service), and whether services should diminish over time as the DDA client found other sources of support in the community.

Service restrictions: Stakeholders reported that the prohibition on receiving community inclusion and employment services at the same time is problematic for clients who remain unemployed the entire nine months or only work a few hours a month. They expressed concern that clients in that situation would be unable to achieve the intended benefits of services.

Provider capacity is unclear and payment rates are lower than for integrated employment

Exhibit 5.1: Growth in community inclusion clients outpaced providers

Source: JLARC staff analysis of DDA client service data.

Legislative Auditor makes two recommendations regarding community inclusion: ensure clients are notified of the option to switch to community inclusion and continue to strengthen and expand the service.

DDA should verify and track whether its staff meet the requirements of RCW 71A.12.290 to offer clients the choice to switch to community inclusion services after nine months of enrollment in an employment program and inform clients of all available options for employment and day services.

DDA should continue to work with counties and stakeholders to strengthen and expand community inclusion services, as required by RCW 71A.12.290.

The Department of Social and Health Services concurs with these recommendations. You can find additional information on the Recommendations tab.

❮ Previous    Next ❯   

As directed by the study mandate, JLARC staff interviewed a variety of stakeholders about the process of requesting, authorizing, and receiving employment and community inclusion services. Our approach reached 232 people from 10 counties across the state. JLARC staff:

• Spoke with individuals and their families through focus groups.
• Interviewed staff from Developmental Disabilities Administration (DDA) and the Division of Vocational Rehabilitation (DVR).
• Interviewed staff from county developmental disability offices and service providers.
• Interviewed staff from advocacy organizations.

These stakeholders told JLARC staff that the system as a whole is complicated. They reported that they had challenges navigating the system and understanding both the programs we reviewed and the broader system. Appendix C provides more information about the themes of the stakeholder comments.

We cannot conclude how many clients experience these difficulties. However, DDA may consider steps to determine if they are widespread and offer possibilities for improvement.

❮ Previous    Next ❯