The Future of Day and Employment services for Adults receiving DDA Waiver Services Jade Ann Gingerich Director of Employment Policy, Maryland Department of Disabilities and MD PROMISE Project Director Jade.gingerich@maryland.gov

What is Changing and When In March 2015, Maryland will need to submit a 5 year transition plan for approval to CMS* to bring all Home and Community Based Waivers, including DDA waivers, into alignment with their new regulations. Note: changes only apply to DDA waiver funded youth Stakeholder input is important: youth, parents, schools, etc Still waiting for CMS guidance related to Non-residential, which would include Day habilitation and Employment

But what we do know is: Emphasis is on settings and ensuring individuals are receiving ALL services in the most integrated settings possible. Taking the de-institutional movement beyond where individuals live to where they work, play and spend their days. * Centers for Medicaid and Medicare

Why is it changing? January 16, 2014 CMS released the following Regulations, in part to ensure that CMS regulations are in alignment with the law, particularly as it relates to the Olmstead decision. Medicaid Program; State Plan Home and Community-Based Services, 5-Year Period for Waivers, Provider Payment Reassignment, and Home and Community-Based Setting Requirements for Community First Choice (Section 1915(k) of the Act) and Home and Community-Based Services (HCBS) Waivers (Section 1915(c) of the Act)

CMS INTENT To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c), 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate •To enhance the quality of HCBS and provide protections to participants

Definitions The Home and Community-Based setting: Is integrated in and supports access to the greater community Provides opportunities to seek employment and work in competitive integrated settings, engage in community life, and control personal resources Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services

What was the Olmstead Decision? The Decision On June 22, 1999, the United States Supreme Court held in Olmstead v. L.C. that unjustified segregation of persons with disabilities constitutes discrimination in violation of title II of the Americans with Disabilities Act. The Court held that public entities must provide community-based services to persons with disabilities when (1) such services are appropriate; (2) the affected persons do not oppose community-based treatment; and (3) community-based services can be reasonably accommodated, taking into account the resources available to the public entity and the needs of others who are receiving disability services from the entity.

Supreme Court Key Decisions Institutional placement of persons who can handle and benefit from community settings perpetuates unwarranted assumptions that persons so isolated are incapable of or unworthy of participating in community life. Confinement in an institution severely diminishes the everyday life activities of individuals, including family relations, social contacts, work options, economic independence, educational advancement, and cultural enrichment.

Why Now? Individuals with disabilities are beginning to challenge segregated day and sheltered employment settings in many states and citing Olmstead. Increased dialogue between US Department of Justice and CMS highlighted need for increased alignment of regulations to law. State lawsuits including OR, RI, VA, GA, and others

US Dept of Justice: Oregon and Rhode Island DoJ Oregon Finding related to Olmstead, lawsuit underway: State was unnecessarily segregating individuals with intellectual and developmental disabilities in sheltered workshops when they could be served in integrated employment settings U.S. v. Rhode Island and City of Providence (and school system); Found that the State and City have unnecessarily segregated individuals with intellectual and developmental disabilities (I/DD) in a sheltered workshop and segregated day activity service program, and have placed public school students with I/DD at risk of unnecessary segregation in that same program

Virginia and US DoJ Settlement Agreement Had 180 days to develop an implementation plan to increase integrated day opportunities for individuals in the target population, including supported employment, community volunteer activities, community recreational opportunities, and other integrated day activities. Number of individuals who are receiving supported employment; Length of time people maintain employment in integrated work settings; Amount of earnings from supported employment; Number of individuals in pre-vocational services as defined in 12 VAC 30-120-211 in effect on the effective date of this Agreement; and Length of time individuals remain in pre-vocational services. Began downsizing residential but then shared community services including employment

Virginia continued And set targets to meaningfully increase: number of individuals who enroll in supported employment each year; and number of individuals who remain employed in integrated work settings at least 12 months after the start of supported employment.

New York Effective July 1, 2013, New York no longer permitted new admissions to sheltered workshops & must report the number of enrollees remaining in sheltered workshops quarterly Only integrated gainful employment at minimum wage or higher will be considered competitive employment. Must also increase the number of persons engaged in competitive employment by 700 persons above previous 12 month enrollment, with no exceptions for attrition during a set time frame.

New York continued New York submitted draft plan for CMS review & final plan January 1, 2014 that had to include baseline data as well as: increase in number of individuals in competitive employment, the number of students exiting education moving directly into competitive employment, a timeline for closing sheltered workshops, & a description of the collaborative work with NY education system for training/education to key stakeholders on the availability/ importance of competitive employment.

What does it mean for Youth funded by DDA waivers? More choices and opportunities to be a part of their communities. The chance to express what they like to do, want to do, are good at, and to offer input into what they want their lives to look like Ability to play a role and provide input/feedback as to what they want/need to be able to live, work and play in their community Opportunity to explore diverse work experiences and development of new interests/friendships/skills where they live

What does all this mean for Families? Need to understand value of employment and the importance of community based programs Need to be able to communicate their concerns and be willing to learn and explore the possibilities Need to be engaged/offer input in the process and provide feedback to create a system in Maryland that meets both CMS expectations and family/youth needs

What this mean for Schools Need to ensure the 18-21 year population in particular are gaining community based employment skills and experience Must convey need to families and youth the need to plan/prepare for post school employment, postsecondary education and community based programs Adult service options will be changing and need to follow those changes Need to ensure all school programs are as integrated as possible (note RI).

What does this mean for DDA Adult Service Providers? Must be prepared to address individual and parent concerns Need to understand the federal and state changes occurring and ensure their programs comply Need to minimize/eliminate facility based and/or segregated programs and focus on community based activities including individualized integrated employment Need to develop staff skills/competencies in job development, customized employment, employer expectations, safety in the community and other areas