Rethinking Day Services in the COVID-19 Era

September 16, 2020
Presentation Overview

1. Pandemic-Related Changes to Day Services

2. COVID-19 Payment Flexibilities and 

Provider Adaptations

3. Innovation in 3 States (with Guest Speakers)

4. Moving Toward Value-Based Payments for 

Day Services

5. Q&A
PANDEMIC-RELATED CHANGES TO 

DAY SERVICES

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Employment and Day Services: A National Snapshot

• Estimated 5,000 – 6,000 providers nationally

• Mostly non-profit organizations

– Non-profit: 85%

– For profit: 6%

– Public (state or tribal): 7%

– Other: 2%

• Most were regional providers

– County or regional scope: 51%

– Local scope: 36%

– Statewide: 8%

– Multi-state: 5%

• Average operational budget (in 2014-15) $3.0 million

• Average number of people served: 2,019

• 60% were funded 51% or more by Medicaid or State I/DD Agency

4

Domin, D., & Butterworth, J. (2016). Research to practice: The 2014-2015 national survey of community rehabilitation providers, 

Report 1: Overview of services, trends, and provider characteristics. https://scholarworks.umb.edu/ici_researchtopractice/46/
Use of Day Services Has Grown Dramatically

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# of Individuals

~100k in day services

~400k in day services
Day Services Depend on 

Multiple Sources of Funding

State-only dollars

Medicaidfinanced LTSS

County-based levies

To CBOs, including 

local chapters of The 

Arc

Grants

Example: California 

Lanterman Act

Example: Missouri 

SB40 boards

1915(c) waivers

1915(i) State Plan option

1115 demonstration waivers

Local coordinating agencies 

(Example: Colorado CommunityCentered Boards)
COVID-19 May Shut Many Disability 

Services Programs for Good

• ANCOR surveyed 191 organizations nationwide.

• 77% have shut down or discontinued programs.

• 16% do not plan to reopen their programs.

• Employment and day services most affected.

• Causes: ↑ costs (PPE, testing); ↓ revenue.

• https://www.disabilityscoop.com/2020/08/24/covid-19-may-shut-many-disabilityprograms-for-good/28795/ (August 2020)

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COVID-19 Has Hit Day Services 

Providers Especially Hard

Pre-Employment Transition Services

Customized Employment

Supported Employment

Adult vocational skills training

Job placement

Individual placement and support

Facility-based pre-vocational supports

Community-based prevocational supports

Facility-based day habilitation

Community-based day habilitation

% of Providers No Longer Providing Services

8

Association of People Supporting Employment First. (2020). Impact of COVID-19 on disability employment 

services and outcomes. https://apse.org/covid-19-impact-survey/
The Arc of California. (2020, August 6). What families are telling us: Disability 

services during pandemic. The Arc of California. https://thearcca.org/what-familiesare-telling-us-disability-services-during-pandemic/

ATTITUDES TOWARD RETURNING TO DAY 

SERVICES

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Most Respondents Were Family Members

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n = 395 respondents
Most Individuals Live at Home

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n = 395 respondents
Vast Majority Want to Return to Day Services

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n = 395 respondents
Some Who Want to Return to Day Services Want Safety Measures

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n = 395 respondents
Some Survey Answers are Hard to Interpret

• Unclear what individuals and families want:

– A desire to do something during the day, 

whether technically “day services” or not?

– Pre-pandemic, facility-based day services?

– Integrated, individualized day services?

• States and providers wishing to duplicate 

the survey should add questions to 

distinguish these possibilities.

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Medicaid Provides Pandemic-Related 

Payment Flexibilities

• Families First Coronavirus Response Act (FFCRA)

– Enhanced FMAP (6.2%)

• Appendix K waiver amendments to support providers:

– Retainer payments

– Rate changes

• Time limited

– Enhanced FMAP: duration of public health emergency

– Appendix K amendments

▪ Three 30-day periods for retainer payments

▪ Must end by March 31, 2021

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# States with Appendix K 

Amendments for Day Services

35

33

29

26

23

18

12

5

0 5 10 15 20 25 30 35 40

Expanded where day services are provided

Modified certification, incident reporting, or participant

monitoring

Authorized retainer payments

Expanded telehealth/electronic service delivery

Increased payment rate or max hours

Authorized family caregivers

Authorized institutional day services

Modified provider qualifications

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Reopening Poses Challenges

Condition of Reopening Impact

Social distancing & space changes Reduced revenue, increased costs

PPE and cleaning supplies New cost center

Transportation Cost-inefficient disability-specific 

transit;

Reduced or eliminated public transit

Workforce return Direct support staff ill, laid off, caring 

for family, or switched professions for 

safety

Contingency plans in case of 

outbreak; plans for continuity of 

operations

Additional planning for individuals and 

staff; disruptions in revenue and 

service delivery

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3Ps: A Framework for Systems Adaptation & Change

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Payers

Providers

People

How are changes shaped by?

How do changes affect?
HARNESSING TECHNOLOGY TO ADAPT AND 

IMPROVE SERVICES: 2 EXAMPLES

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Remote Learning Center

PathPoint (Southern California)

https://www.pathpoint.org/

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Online 

classes in 

exercise, 

music, 

cooking, 

dance, etc.
Remote Supports

Ohio State University Nisonger Center: 

https://nisonger.osu.edu/adult/resources/technology-project/remote-supports/

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Resources 

for helping 

individuals 

live 

independently with 

technology
Innovations in 3 States

1. St. Louis Arc: Virtualizing Services

2. The Arc of Tri-Cities, WA: Supplementing 

workforce with volunteers

3. Managed Resource Connections, Inc. 

(MRCI) of MN: Moving away from brickand-mortar model of day services

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Guest Speakers

• St. Louis Arc: Gabrielle Szarek, Director of 

Transition Services

• Arc of Tri-Cities

– Cindy O’Neill, Executive Director

– Monti Franckowiak, mother and advocate

• MRCI: Brian Benshoof, CEO

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St. Louis Arc Has Successfully 

Virtualized Many Service (1/2)

• Daily Boost

– 30-minute segments, 2-3x weekly

– Short mental breaks for teens and young adults to share positive 

messages and related content

▪ Virtual escape rooms

▪ In-home scavenger hunts

• Teach Something/Learn Something

▪ 30-minute segments, 1x weekly or more

▪ Helps participants work on communication and public speaking skills

• “Launch” Program

– Combination of individual coaching sessions and group classes for 

transition-aged teens and young adults

– Because Launch is paid for privately, it can be taken nationwide –

increasing revenue.

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St. Louis Arc Has Successfully 

Virtualized Many Service (2/2)

• Virtual family workshops

– Tips and activities that can be done at home

– Resources in the St. Louis area that can be 

accessed for free or nearly free

• Facebook Live Q&A

– Every Tuesday hosted by Director of Family 

Supports

– Attendance ranges from 500-900

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Uses Volunteers to Grow its 

Workforce

• Dedicated group of youth who volunteer during the 

summer, often moving over successive summers 

toward full-time employment.

• Local teenagers not going to school on campus, so 

won’t have access to typical extracurricular 

activities.

• Plan to have teenagers supplement full-time staff: 

paid staff 2:1 or 3:1, with additions of volunteers to 

bring the ratio down further.

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Testimonial: Yuriy Moved from 

Volunteer to Staffer at Tri-Cities

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Reducing Costs by Closing 

Brick-and-Mortar Locations

• MRCI serves more than 2,000 individuals across 

Minnesota with employment and day services.

• Plans to sell buildings or not renew leases on rentals.

• Reductions in expenses for:

– Maintenance

– Heating/cooling

– Insurance, etc.

• Reduced use of transportation getting individuals to 

and from these facilities.

• Long-term move to “day services without walls.”

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Adaptation and Innovation Benefit 

Providers and People

Benefits to Providers: Lower Costs, More 

Sustainable Business Models

Benefits to People: Improved Choice and 

Community Integration

Reduced brick-and-mortar costs Greater independence through remote 

supports

Selling private pay services on a national 

scale to grow revenue

Enhanced choice: virtual or in-person

Using volunteers to diversify workforce and 

lower labor costs

Enhanced choice: pathways for personal 

growth and the pursuit of individual interests

Enhanced integration: virtual communities

Enhanced integration: in-community day 

supports

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Reminder: Day services are services not places.
Innovation Poses Challenges

• Remote/virtualized services won’t be a good fit for 

everyone.

– Uneven access to/comfort with broadband & devices

– Can induce behavioral challenges

▪ Hunger strikes

▪ Refusal to leave house or elopement

▪ Increased risk of institutionalization

• Day services offered in the community don’t 

guarantee meaningful integration.

• The question is what to keep, for whom, when.

30
Ciulla, J., & Sulewski, J. S. (2016). High-quality community life engagement 

supports: Four guideposts for success. UMass Boston Institute for Community 

Inclusion. https://www.thinkwork.org/high-quality-community-life-engagementsupports-four-guideposts-success

AN OPENING TO REINVENT SERVICES? 

“GUIDEPOSTS” FOR QUALITY SERVICES

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Changing Language is the First Step to 

Making Day Services More Integrated

• Names reflect values

• Two common alternatives:

– “Community inclusion”

– “Community life engagement” (CLE)

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CMS Has Released Guidance on 

Value-Based Payments & Medicaid

• Released September 15, 2020

• State Medicaid Directors Letter

– https://www.medicaid.gov/Federal-PolicyGuidance/Downloads/smd20004.pdf

• Fact Sheet

– https://www.cms.gov/newsroom/fact-sheets/value-based-carestate-medicaid-directors-letter

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Value-Based Payment Systems 

Can Take Several Forms

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Health Care Payment Learning & Action Network. (2017). Alternative payment model (APM) framework. 

http://hcp-lan.org/workproducts/apm-refresh-whitepaper-final.pdf
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Health Care Payment 

Learning & Action Network. 

(2017). Alternative payment 

model (APM) framework. 

http://hcplan.org/workproducts/apmrefresh-whitepaper-final.pdf

Common 

Pathways:

Category 1 →

Category 2B →

Category 4
VBP for HCBS Roadmap

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Medicaid Innovator Accelerator Program. 

(2019, September 4). Value-based 

payment for home and community-based 

services: Strategies, progress, and 

accomplishments of participating IAP 

states. https://www.medicaid.gov/stateresource-center/innovation-acceleratorprogram/iap-downloads/programareas/vbp-hcbs-strat-prog-accomwebinar.pdf
Guideposts to Value-Based Payments 

for CLE: UMass Boston ICI (1/2)

1. Individualize supports for each person

– Show understanding of personal preferences, 

interests, and skills

– Emphasize person-centered planning and discovery

– Consider creative grouping, staffing, and scheduling

2. Promote community membership and contribution

– Start with inclusive settings and activities

– Ensure staff presences does not limit connections with 

other community members

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Guideposts to Value-Based Payments 

for CLE: UMass Boston ICI (2/2)

3. Use human social capital to decrease dependence 

on paid supports

– Create natural supports (e.g., yoga class)

– Individuals can bootstrap into other integrated activities, 

including supported employment

4. Ensure that supports are outcome-oriented and 

regularly monitored

– Emphasize individuals’ goals rather than processes (# of 

hours on an activity)

– Should lead to or complement employment

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Move Ahead Despite an Absence 

of Standards

• No standards yet exist for the quality of day 

services.

• The lack of standards need not prevent 

progress.

• Better to move ahead with what you have: 

Some progress is better than none.

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Determine Which Data To Collect

(Guideposts for Quality Services)

1. Are supports individualized?

2. Do supports promote community 

membership and contribution?

3. Do supports use social capital to 

decrease dependence on paid supports?

4. Do supports help individuals achieve their 

personal goals?

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Additional Resources 

• California’s DD System Plans to Move to Value-Based Purchasing (VBP)

– Governor’s budget for FY2021 included a shift to VBP for its ID/DD services.

– Proposal analyzed by non-partisan Legislative Analyst’s Office (LAO) – California’s 

equivalent of the Congressional Budget Office (CBO).

– Petek, G. (2020). The 2020-21 budget: Analysis of the Department of Developmental 

Services budget. California Legislative Analyst’s Office. 

https://lao.ca.gov/Publications/Detail/4147

• Medicaid HCBS VBP Website

– Medicaid Innovator Accelerator Program. (2019, September 4). Value-based payment 

for home and community-based services: Strategies, progress, and accomplishments 

of participating IAP states. https://www.medicaid.gov/state-resource-center/innovationaccelerator-program/iap-downloads/program-areas/vbp-hcbs-strat-prog-accomwebinar.pdf

• Quality measures

– NQF provides guidance to HHS for measuring the quality of home and communitybased services. (2017). Retrieved September 16, 2020, from 

http://www.qualityforum.org/HCBS.aspx

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Q & A Discussion

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What’s Next?

▪ To request additional information or contact 

a panelist, email AOD@acl.hhs.gov

▪ Registered participants will receive a link 

once slides are publicly posted 

▪ Email to come to evaluate this webinar

▪ Next month: 

▪ Transportation Services, September 30

▪ Different time: 3pm Eastern/12pm Pacific

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