Employment and Community Inclusion Services for People with
Developmental Disabilities
Legislative Auditor's Conclusion:
The Developmental Disabilities Administration prioritizes services
that help clients get jobs in the community. It does not determine how its services
impact individual clients’ quality of life.
The 2017 operating budget directed the Joint Legislative Audit and Review Committee
(JLARC) to evaluate employment and community inclusion services for persons with
developmental disabilities. The Developmental Disabilities Administration (DDA)
oversees services through program agreements with county developmental disability
authorities. Most counties contract with private companies to provide services.
DDA prioritizes individual employment services
Individual supported employment services assist clients with finding jobs in
integrated community work places that pay at least minimum wage. DDA prioritizes this
service over other employment and community inclusion services. See tab 2
for more detail.
Washington leads the nation in helping clients get jobs. However, few of them meet
DDA’s objective of earning a living wage.
Compared to other states, Washington has the highest percent of clients enrolled in
integrated employment services. The goal of individual supported employment services
is gainful employment, which DDA defines as clients' achievement of, or progress
towards, earning enough money to meet their living expenses. JLARC staff analyzed
client data and found that 10% of clients earned a living wage (i.e., more than the
federal poverty level). See tab 3
for more detail.
DDA does not directly measure quality of life outcomes for its employment and
community inclusion programs
DDA intends that its services provide quality of life benefits for clients, such as
choice, relationships, integration in the community, and competence. However, DDA does
not measure quality of life outcomes, so it is unable to systematically determine if
clients are receiving them. Although measuring quality of life outcomes is
challenging, specialists in the field identify best practices, included in this
report. See tab 4
for more detail and Appendix
D for the specialists' report on best practices.
DDA does not verify or track whether individuals are offered the choice to switch to
community inclusion services
By law, DDA clients cannot receive employment and community inclusion services at the
same time. Nearly all clients start with employment services. After nine months, the
law requires DDA to offer community inclusion services to clients. DDA does not verify
whether it meets that mandate. See tab 5
for more detail.
Stakeholders told JLARC staff that the service system is complicated
JLARC staff interviewed a variety of stakeholders about the process of requesting,
authorizing, and receiving employment and community inclusion services. Clients and
families reported that they had challenges navigating the system and understanding
both the programs we reviewed and the broader system. See tab 6
for more detail.
Legislative Auditor recommends developing a system to measure quality of life
outcomes and implementing statutory requirements for community inclusion
The Legislative Auditor makes three recommendations. DDA should:
Develop a system to measure quality of life outcomes for its clients.
Ensure that eligible clients are offered the choice of community inclusion after
nine months in employment services.
Report to the Legislature on its efforts to strengthen and expand the community
inclusion program, including an analysis of provider capacity and rate structure.
The Department of Social and Health Services concurs with these recommendations. You
can find additional information on the Recommendations tab.
Proposed Final Report: Employment and Community Inclusion Services for People with
Developmental Disabilities
January 2019
Report Details
1. DDA's service authorization process
DDA authorizes employment and community inclusion services based
on client needs and available state funds
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.
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.
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.
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.
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.
Proposed Final Report: Employment and Community Inclusion Services for People with
Developmental Disabilities
January 2019
Report Details
2. DDA prioritizes individual employment services
The Developmental Disabilities Administration prioritizes
individual supported employment over other employment services and community inclusion
services
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
Four phases of individual supported employment
Phase I includes “getting to know you” activities and basic job
preparation. Phase I includes developing a resume, practicing interviewing
skills, and working on appearance and behavior expectations.
Phase II includes looking and applying for jobs. Phase II activities
are sometimes completed on a client's behalf by service provider staff,
although some clients will be actively involved.
Phase III happens when a client is working, and includes supports such
as job coaching to help the client stay in their job.
Phase IV is record-keeping and applies to activities in all other
phases.
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.
Spending on the other employment services is declining
DDA currently offers two other employment services: prevocational and group
supported employment. Both are meant to be a step on the pathway to employment in an
integrated setting. Providers, which also employ clients, are allowed by state and
federal law to pay clients less than minimum wage for the work.
Prevocational services clients typically work in facilities where most employees
are persons with developmental disabilities. They typically perform simple
assembly tasks.
Group supported employment clients work in supervised groups of eight or fewer
clients. The group works in an integrated setting. A typical example is a
janitorial or landscape crew.
These services tend to provide clients with high support needs with more paid work
hours than individual employment services. For example, in fiscal year 2018, clients
with high support needs worked, on average, 40 hours per month in group supported
employment and 47 hours per month in prevocational services. Clients with high
support needs who received individual employment services worked an average of 21
hours per month.
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:
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.
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.
Proposed Final Report: Employment and Community Inclusion Services for People with
Developmental Disabilities
January 2019
Report Details
3. Many employed, few earn living wage
While Washington leads the nation in helping clients get jobs,
few of them meet DDA’s objective of earning a living wage
Compared to other states, Washington has the highest percent of clients
enrolled in integrated employment services
The Washington State Developmental Disability 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.
Proposed Final Report: Employment and Community Inclusion Services for People with
Developmental Disabilities
January 2019
Report Details
4. DDA does not measure quality of life outcomes
DDA does not directly measure quality of life outcomes for its
employment and community inclusion programs
DDA's six quality of life benefits
Power and Choice – Making our own choices and directing our own lives.
Relationships – Having people in our lives whom we love and care about
and who love and care about us.
Status/Contribution – Feeling good about ourselves and having others
recognize us for what we contribute to others and our community.
Integration – Being a part of our community, through active
involvement. This means doing things we enjoy as well as new and interesting
things.
Competence – Learning to do things on our own or be supported to do
things for our self.
Health and Safety – Feeling safe and secure, and being healthy.
The Washington State Developmental Disability 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
Indicator
Applicability
Limitations
Hours worked
Employment services
May not reflect hours they wish to work or quality of their work experience.
Does not apply to unemployed clients.
Wages
Employment services
Does not apply to unemployed clients.
Service hours
Employment services; community inclusion services
Service hours are not necessarily time client is in community – includes time
provider spends on client's behalf (e.g., contacting employers, completing
paperwork).
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.
A benefit-cost analysis:
Analytical method for comparing the benefits and costs over time of a
policy change or program against another option or the status quo.
Includes a range of benefit and cost categories, across individuals,
government, and society.
Must be able to assign a monetary value to the benefits and costs that are
identified.
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.
Proposed Final Report: Employment and Community Inclusion Services for People with
Developmental Disabilities
January 2019
Report Details
5. DDA does not verify if clients are offered community inclusion
State law requires that DDA clients be given the choice to
transition to community inclusion services after nine months. DDA does not verify or
track whether the mandate is met.
Community inclusion is the primary alternative to employment services
Common Community Inclusion Examples
Joining a club
Volunteering at a nonprofit
Taking an art class
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 Disability
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.
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
Since 2011, the number of providers has increased more slowly than the number of
clients for community inclusion services (see Exhibit 5.1).
Some areas of the state have reported capacity issues. For example, although King
County had 12 community inclusion service providers in fiscal year 2018, county
staff reported that providers were unable to accept new clients. King County had 271
community inclusion clients in fiscal year 2018.
DDA caps compensation for community inclusion providers at $35 per hour, which is
$40 per hour less than individual supported employment. Some providers and county
staff reported that the reimbursement rate does not cover the providers' cost of
delivering the service. In interviews, providers said they offer the service because
they believe it is valuable for clients. Some providers reported that they cover
costs with income from providing individual supported employment services or, if
they are non-profit agencies, with donations.
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.
Proposed Final Report: Employment and Community Inclusion Services for People with
Developmental Disabilities
January 2019
Report Details
6. Stakeholders share experiences
Stakeholders told JLARC staff that the service system is
complicated
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.
Proposed Final Report: Employment and Community Inclusion Services for People with
Developmental Disabilities
January 2019
Report Details
Appendix A: Steps to request and authorize services
DDA-funded employment and community inclusion services are part
of a larger system of services designed to help adults with developmental disabilities
live in the community instead of an institution.
The four basic steps to access employment and community inclusion services are
summarized below:
Step 1: Apply to become DDA client
Individuals must complete a Developmental Disabilities Administration (DDA)
eligibility application and submit supporting documentation. 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.
Once eligible, clients may request services at any time by contacting DDA.
Clients that meet financial eligibility requirements and have a current need for
services may be eligible to receive DDA-funded services. Clients that do not are
placed on the no-paid services list, and DDA does not provide services to them.
If the client's circumstances change (e.g., they meet financial eligibility
requirements), the client or their representative can request that DDA
transfer them to the paid service list and continue to Step 2.
Exhibit A1: For most clients, the path to getting services involves four
steps
Source: JLARC staff summary of process, based on interviews and DDA
documentation.
Step 2: Participate in an assessment to determine service and support needs
Once a client requests paid services from DDA, the client's case manager will
schedule an assessment. The assessment takes place at the client's home and involves
the case manager, the client, relevant service providers, and, if the client wishes,
family, friends, and advocates.
DDA uses a proprietary software program to conduct the assessment. The assessment
determines what a client needs, services they are eligible for, and the level of
support a client requires for employment and community inclusion (high, medium, or
low).
It also determines whether a client would qualify for care in an institutional
setting, which is necessary to move to Step 3.
Information from the assessment is used to develop the service plan in Step 4.
Step 3: Request a Home and Community Based Services waiver
HCBS Waiver
A waiver is a package of services for specific Medicaid populations. They
are called waivers because the state waives certain requirements of federal
Medicaid legislation, and clients waive their rights to receive services in an
institution.
The majority of clients that receive DDA-funded employment or community inclusion
services are on a Medicaid Home and Community Based Services (HCBS) waiver. The most
common waiver for adults is the Basic Plus waiver, which includes 20 different
services, including employment and community inclusion. The Core waiver also
includes employment and community inclusion services, and the Community Protection
waiver includes employment services.
Clients must submit a request for a waiver. Waiver participation is limited. A
committee approves or denies waiver applications based on key factors such as:
The likelihood that a client would require institutionalization if the waiver
were not approved.
The unmet need(s) that could be met with a waiver service.
Exhaustion of other resources to address the need(s).
Whether the client is part of a "priority population" identified in legislative
budgets and WAC
388-845-0045. For the past several years the Legislature has included
students with a developmental disability graduating high school at age 21 that
want to work as a priority population.
Availability of funding.
If the committee approves the request, the client then must request a financial
eligibility review. If the request is denied, the client may still be eligible for
other services such as personal care services. Personal care services help
individuals with daily living tasks, such as eating, bathing, and toileting.
Once a client is approved for a waiver, they can move on to Step 4 and be
authorized for services.
Percent of waivers denied for lack of funding decreased after a new waiver was
introduced
JLARC staff were asked to review the number of requests for the Basic Plus waiver
that were denied due to lack of funding. Exhibit A2 displays the number of
applications and percent of denials from fiscal years 2008-2018. The number of
denials decreased after DDA introduced a new waiver called Individual and Family
Services in 2015. That waiver became the first option for many new clients, instead
of Basic Plus.
Exhibit A2: Requests for the Basic Plus waiver from fiscal years 2008-2018
Fiscal Years
Number of Applications
Approved
Denied - Lack of Funding
Denied - Other Reasons
2008-2014
3,736
63%
33%
4%
2015-2018
3,478
85%
13%
2%
Source: DDA client waiver request data fiscal years 2008-2018.
Step 4: Develop a service plan with DDA case manager
A case manager works with the client to develop a service plan, using information
gathered during the assessment. The service plan documents all services the client
may receive, as well as their support level and service hours.
Authorized service hours are based on client support needs
Everyone is assigned a level of support for both employment and community inclusion
services. The higher a client's support needs, the more service hours they can be
authorized to receive from a provider. Service hours reflect time that a provider is
assisting clients with activities in the community, as well as the provider's time
for paperwork, searching for jobs or activities, and other support functions.
In general, the authorized monthly service hours for employment can range from 4
to 26. In some circumstances, a client may be authorized for more than 26 hours on
a short-term basis.
The authorized service hours for community inclusion can range from 3 to 20 per
month.
The average number of service hours providers billed per client in FY2018 is
displayed in Exhibit A3.
Exhibit A3: Average provider service hours billed per month for employment and
community inclusion in fiscal year 2018
Support need
Individual employment
Group employment
Prevocational
Community inclusion
All clients
10
10
13
12
High
13
11
14
13
Medium
9
9
12
10
Low
6
7
n/a
6
Note: There were no prevocational clients with low support needs in fiscal year
2018.
Source: JLARC staff analysis of DDA provider billing data.
Clients select a service provider and begin services
The client selects a provider for each authorized service. For employment or
community inclusion services, the case manager sends an authorization form to the
developmental disability authority in the county where the selected provider is
located. The county sends the authorization to the selected provider.
Absent a specific exemption, all clients start with employment services and cannot
participate in community inclusion until they have tried employment services for at
least nine months.
Some clients are referred to another service
The process above omits the potential that a client may be referred to the DSHS
Division of Vocational Rehabilitation (DVR) for employment services. This could
happen at any of the steps above. DVR offers short-term employment services for
clients with disabilities, however the logistics of the services are different. DVR
processes are not a focus of this study.
Proposed Final Report: Employment and Community Inclusion Services for People with
Developmental Disabilities
January 2019
Report Details
Appendix B: Interactive data
This appendix includes additional detail on number of clients
served, amount spent, client earnings, and hours clients worked.
Clicking on the images below will take you to a different website with interactive
data charts. The data covers fiscal years 2014-18. Data before fiscal year 2014 are
excluded because the Developmental Disabilities Administration (DDA) changed its
method of calculating clients' level of support need and its method of paying
providers. The data includes only clients who were both authorized for and recipients
of an employment or community inclusion service.
Clients served by service type and fiscal year
Use this data to:
Filter by service (community inclusion, individual supported, group supported,
prevocational).
Filter by level of support need (low, medium, high).
View totals by fiscal year.
Exhibit B1: Clients served by service type and level of support need for fiscal
years 2014-18.
Click on image to enable interactive data filtering (clicking on image will take you
to another website called Tableau Public).
Source: DDA client data from fiscal years 2014-18.
Amount spent by service type and fiscal year
Use this data to:
Filter by service (community inclusion, individual supported, group supported,
prevocational).
Filter by level of support need (low, medium, high).
View totals by fiscal year.
Exhibit B2: Amount spent by service type and level of support need for fiscal years
2014-18.
Click on image to enable interactive data filtering (clicking on image will take you
to another website called Tableau Public).
Source: DDA expenditure data from fiscal years 2014-18.
Average monthly client earnings by employment service type and fiscal year
This data excludes clients who did not have any earnings.
Use this data to:
View average monthly client earnings for each level of support need (high, medium,
and low).
Filter by employment service (individual supported, group supported, and
prevocational).
Filter by fiscal year.
Exhibit B3: Average monthly client earnings for fiscal years 2014-18.
Click on image to enable interactive data filtering (clicking on image will take you
to another website called Tableau Public).
Source: DDA client wage data from fiscal years 2014-18.
Average paid hours each month by type of employment service and fiscal year
This data excludes clients who did not have any paid hours.
Use this data to:
View average number of paid hours clients worked per month by level of support
need (high, medium, and low).
Filter by employment service (individual supported, group supported, and
prevocational).
Filter by fiscal year.
Exhibit B4: Average monthly hours clients worked for fiscal years 2014-18.
Click on image to enable interactive data filtering (clicking on image will take you
to another website called Tableau Public).
Source: DDA client data from fiscal years 2014-18.
Proposed Final Report: Employment and Community Inclusion Services for People with
Developmental Disabilities
January 2019
Report Details
Appendix C: Stakeholders reported challenges with navigating services
JLARC staff were directed to seek input from stakeholders. They
reported that the service delivery system is complicated and can be difficult to
navigate.
Over the course of this study, JLARC staff spoke with 232 people from a number of
stakeholder groups across the state including:
Individuals with developmental disabilities and their family members.
Developmental Disabilities Administration (DDA).
Division of Vocational Rehabilitation (DVR).
County developmental disability offices from 10 counties.
Employment and community inclusion service providers.
Advocacy organizations.
This approach was designed to capture a range of perspectives and experiences across
the state, and is not intended to be a representative sample of all DDA clients.
Stakeholders reported the following types of challenges:
Getting clear information about processes and/or services.
For example, some clients and families may not have a clear understanding
about how to access paid services from DDA or what services they are eligible
for. There were many examples of clients learning about service options and
processes from other families or through participation in a parent and family
support group.
Understanding how different entities fit into the overall service delivery
system.
Clients indicated that they received information about their services from
multiple federal, state, and local agencies, in addition to private service
providers. We heard that when individuals and families did not understand how
these agencies and entities are connected, they could be confused by the
communications.
Experiencing lack of coordination between DDA and DVR.
DDA and DVR both offer employment services to persons with developmental
disabilities. The agencies have different terminology, data and case management
systems, and processes for serving clients. In some parts of the state, DDA and
DVR offices do not have procedures to coordinate employment services. Clients,
families, DDA case managers, and DVR counselors reported that poor coordination
had resulted in confusion and inefficiencies.
DDA and DVR have taken steps to address this issue, independent of this
audit. A new memorandum of understanding was signed by DVR and DDA in August
2018 that aims to improve coordination of services across the state.
Understanding how employment may impact Social Security benefits.
Clients' earnings may be subtracted from their Social Security benefits, and,
if they earn enough money, they may no longer be eligible for Social Security.
Losing eligibility for Social Security may impact eligibility for other
benefits, such as DDA paid services and Medicaid.
Professional benefit planners can help clients and families understand the
effect of earnings on their benefits.
Although DVR and a few county developmental disability offices each employ
benefit planners, stakeholders told JLARC staff that most clients do not have
access to these professional services. Stakeholders said that, without benefit
planning assistance, some clients may avoid employment services altogether.
Proposed Final Report: Employment and Community Inclusion Services for People with
Developmental Disabilities
January 2019
Report Details
Appendix D: Specialist report on measuring quality of life outcomes
JLARC staff contracted with industry specialists to understand
best practices for measuring quality of life outcomes
Click here to read the Review and Analysis of Employment and Community Inclusion
Measurement prepared by the Research and Training Center on Home and Community Based
Services Outcome Measurement at the Institute on Community Integration, University of
Minnesota.
Proposed Final Report: Employment and Community Inclusion Services for People with
Developmental Disabilities
January 2019
Report Details
Appendix E: Applicable Statutes and Rules
RCW 71A.12.290, WAC 388-825-056, WAC
388-845-0045
Transition from employment services to community access program.
RCW 71A.12.290
(1) Clients age twenty-one and older who are receiving employment services must be
offered the choice to transition to a community access program after nine months of
enrollment in an employment program, and the option to transition from a community
access program to an employment program at any time. Enrollment in an employment
program begins at the time the client is authorized to receive employment.
(2) Prior approval by the department shall not be required to effectuate the
client's choice to transition from an employment program to community access services
after verifying nine months of participation in employment-related services.
(3) The department shall inform clients and their legal representatives of all
available options for employment and day services, including the opportunity to
request an exception from enrollment in an employment program. Information provided to
the client and the client's legal representative must include the types of activities
each service option provides, and the amount, scope, and duration of service for which
the client would be eligible under each service option. An individual client may be
authorized for only one service option, either employment services or community access
services. Clients may not participate in more than one of these services at any given
time.
(4) The department shall work with counties and stakeholders to strengthen and expand
the existing community access program, including the consideration of options that
allow for alternative service settings outside of the client's residence. The program
should emphasize support for the clients so that they are able to participate in
activities that integrate them into their community and support independent living and
skills.
(5) The department shall develop rules to allow for an exception to the requirement
that a client participate in an employment program for nine months prior to
transitioning to a community access program.
What benefits do DDD paid services provide to me?
WAC 388-825-056
DDD paid services provide one or more of the following benefits:
(1) An opportunity to learn, improve or retain social and adaptive skills necessary
for living in the community;
(2) Health and safety;
(3) Personal power and choice;
(4) Competence and self reliance;
(5) Positive recognition by self and others;
(6) Positive relationships; and
(7) Integration into the physical and social life of the community.
When there is capacity to add people to a waiver, how does DDA determine who will be
enrolled?
WAC 388-845-0045
When there is capacity on a waiver and available funding for new waiver participants,
DDA may enroll people from the statewide database in a waiver based on the following
priority considerations:
(1) First priority will be given to current waiver participants assessed to require a
different waiver because their identified health and welfare needs have increased and
these needs cannot be met within the scope of their current waiver.
(2) DDA may also consider any of the following populations in any order:
(a) Priority populations as identified and funded by the legislature.
(b) Persons DDA has determined to be in immediate risk of ICF/IID admission due to
unmet health and welfare needs.
(c) Persons identified as a risk to the safety of the community.
(d) Persons currently receiving services through state-only funds.
(e) Persons on an HCBS waiver that provides services in excess of what is needed to
meet their identified health and welfare needs.
(f) Persons who were previously on an HCBS waiver since April 2004 and lost waiver
eligibility per WAC 388-845-0060 (1)(i).
(3) DDA may consider persons who need the waiver services available in the basic plus
or IFS waivers to maintain them in their family's home or in their own home.
Proposed Final Report: Employment and Community Inclusion Services for People with
Developmental Disabilities
January 2019
Recommendations & Agency Response
Legislative Auditor Recommendation
The Legislative Auditor makes three recommendations regarding
DDA’s employment and community inclusion services
Recommendation #1: DDA should implement a system to measure quality of life outcomes
for its clients in employment and community inclusion services
As it develops a measurement system, the Developmental Disabilities Administration
(DDA) should:
Design the system to measure the intended quality of life benefits identified in WAC
388-825-056.
Consult with industry experts and stakeholders to design a system that incorporates
best practices.
Structure the system so that the results can be used to inform policy and
programmatic decisions.
DDA should identify resources needed for the measurement system, including options for
implementing it within current budget levels.
DDA has the highest percent of clients enrolled in integrated employment services in
the country. However, in the absence of a system of measurement, DDA cannot know whether
clients are achieving improvements in quality of life. Specialists at the Research and
Training Center on Outcome Measurement acknowledge that measuring quality of life is
challenging. However, they assert that measures can be identified that allow the state
to make more informed decisions about policy, resource allocation, and programs.
Legislation Required:
No
Fiscal Impact:
DDA should identify resource needs
Implementation Date:
Annual progress reports should be provided to the Legislature and Legislative
Auditor by September, starting in 2019
Recommendation #2: DDA should ensure that all clients are notified of the option to
switch to community inclusion services
DDA should verify and track whether its staff follow the legislative requirements in RCW
71A.12.290 to:
Offer clients the choice to switch to community inclusion services after nine months
of enrollment in an employment program.
Inform clients of all available options for employment and day services, including
the opportunity to request an exception from enrollment in an employment program.
DDA does not track or verify whether individual clients have been offered the choice to
switch to community inclusion services. It does not have a policy on when or how case
managers or other staff offer the choice.
Legislation Required:
No
Fiscal Impact:
JLARC staff assume DDA can implement within existing resources
Recommendation #3: DDA should continue to strengthen and expand community inclusion
services
As required by RCW
71A.12.290, DDA should continue to work with counties and stakeholders to
strengthen and expand community inclusion services. In doing so, DDA should continue its
efforts to train and assist service providers. It also should analyze the service
capacity in each county and the sufficiency of payment rates for providers.
Legislation Required:
No
Fiscal Impact:
JLARC staff assume training and analysis can be done within existing resources.
Other steps may require additional resources.
Proposed Final Report: Employment and Community Inclusion Services for People with
Developmental Disabilities
January 2019
Recommendations & Agency Response
Department of Social and Health Services Response
Proposed Final Report: Employment and Community Inclusion Services for People with
Developmental Disabilities
January 2019
Recommendations & Agency Response
Other Responses
The Office of Financial Management (OFM) was given an opportunity to comment on this
report. OFM responded that it does not have any comments.
Proposed Final Report: Employment and Community Inclusion Services for People with
Developmental Disabilities
January 2019
More About This Review
Audit Authority
The Joint Legislative Audit and Review Committee (JLARC) works to make state
government operations more efficient and effective. The Committee is comprised of an
equal number of House members and Senators, Democrats and Republicans.
JLARC's non-partisan staff auditors, under the direction of the Legislative Auditor,
conduct performance audits, program evaluations, sunset reviews, and other analyses
assigned by the Legislature and the Committee.
The statutory authority for JLARC, established in Chapter 44.28 RCW,
requires the Legislative Auditor to ensure that JLARC studies are conducted in
accordance with Generally Accepted Government Auditing Standards, as applicable to the
scope of the audit. This study was conducted in accordance with those applicable
standards. Those standards require auditors to plan and perform audits to obtain
sufficient, appropriate evidence to provide a reasonable basis for findings and
conclusions based on the audit objectives. The evidence obtained for this JLARC report
provides a reasonable basis for the enclosed findings and conclusions, and any
exceptions to the application of audit standards have been explicitly disclosed in the
body of this report.
Proposed Final Report: Employment and Community Inclusion Services for People with
Developmental Disabilities
January 2019
More About This Review
Study Questions
Why a JLARC Study of Employment and Community Access Services?
The 2017 operating budget (ESSB 5883) directed the Joint Legislative Audit and Review
Committee (JLARC) to conduct a performance audit of employment and community access
services offered by the Department of Social and Health Services (DSHS) for people
with a developmental disability.
Employment services include job placement and support, such as job coaches.
Prevocational services are a type of employment service.
Community access services are meant to promote skill development, independent
living, and community integration.
Employment and community access services are available to eligible individuals over
the age of 21, subject to funding. Individuals cannot receive both services at the
same time.
Within DSHS, the Developmental Disabilities Administration (DDA) is largely
responsible for overseeing the services. It contracts with counties, which either
provide services directly or subcontract with employment or community access service
providers.
Study Objectives
What is the process of requesting, authorizing, and receiving employment services,
including prevocational services, or community access services?
What criteria are used to make decisions about authorizing or denying a
request for services?
What are the roles and responsibilities of those involved, including job
coaches?
What are the costs of the services? What types of costs are borne by those
affected (e.g., individuals, families, providers, employers, the state)?
Is it possible to quantify all costs with available data?
What are the types of benefits (tangible and intangible) of the services? Who
receives the benefits (e.g., individuals, families, providers, employers, the
state)?
Can the types of benefits be quantified and/or measured?
What approach would be necessary to link benefits directly to the
services?
What information would be necessary to conduct a benefit-cost analysis of
employment or community access services?
Study Timeframe
Staff will present the preliminary report in December 2018 and the final report in
January 2019.
More about Employment and Community Access Services
Within DSHS, employment and community access services are primarily overseen by DDA.
Another part of DSHS, the Division of Vocational Rehabilitation (DVR), also helps
individuals with developmental disabilities secure employment.
Three types of employment services offered through DDA
DDA offers three types of employment services to adults who are 21 and older and have
a developmental disability:
Individual supported employment helps individuals find and maintain employment in
the general workforce. They earn minimum wage or more. DDA may provide additional
training or support, as needed, based on the individual’s level of disability.
Group supported employment offers ongoing supervised employment for groups of
eight or fewer individuals with disabilities in the same setting. Individuals have
opportunities to interact with the public.
Prevocational services are intended to be short term. Groups of individuals learn
skills and receive training to prepare them for employment in the general workforce.
Individuals do not have regular interactions with the public at work. Prevocational
services are being phased out and will not be offered after 2019.
Community access services available after participation in employment services
Community access services “promote skill development, independent living, and
community integration for individuals learning how to actively and independently
engage in their community” (WAC 388-845- 0600). As of September 2017, DSHS also refers
to these services as "community inclusion."
Individuals can receive community access services after they have participated in
employment services for nine consecutive months. If they do not get a job or decide
they do not want to be on an employment path, then they can switch to community
access. DDA can grant an exception to this rule, allowing individuals to participate
in community access services without first trying employment services.
Proposed Final Report: Employment and Community Inclusion Services for People with
Developmental Disabilities
January 2019
More About This Review
Methodology
The methodology JLARC staff use when conducting analyses is tailored to the scope of
each study, but generally includes the following:
Interviews with stakeholders, agency representatives, and other
relevant organizations or individuals.
Site visits to entities that are under review.
Document reviews, including applicable laws and regulations,
agency policies and procedures pertaining to study objectives, and published
reports, audits or studies on relevant topics.
Data analysis, which may include data collected by agencies
and/or data compiled by JLARC staff. Data collection sometimes involves surveys or
focus groups.
Consultation with experts when warranted. JLARC staff consult
with technical experts when necessary to plan our work, to obtain specialized
analysis from experts in the field, and to verify results.
The methods used in this study were conducted in accordance with Generally Accepted
Government Auditing Standards.
More details about specific methods related to individual study objectives are
described in the body of the report under the report details tab or in technical
appendices.
Proposed Final Report: Employment and Community Inclusion Services for People with
Developmental Disabilities