Rethinking Employment Services 

and Supports in the COVID-19 Era

August 5, 2020
“Real Work for Real Pay in the Real World”

From California Competitive Integrated Employment Blueprint 

Goal: Competitive Integrated Employment (CIE)

Employment where a person with disabilities:

– Makes the same wage as a person without a disability

– Receives the same benefits

– Has the same opportunities for advancement

In the community, where most people do not have 

disabilities

Includes part-time or full-time work or having one’s 

own business 

2
Only 27% of adults with cognitive disabilities 

(Ages 16-64) were employed in 2018

Source: American Community Survey data from StateData: The National Report on Employment 

Services and Outcomes Through 2017 

3
Employment Services Depend on Multiple 

Sources of Funding

4
HCBS Waiver Funded Employment Services

5

Career 

Planning

• Basic job 

skills 

• Vocational 

assessment 

and career 

planning 

• Instruction 

on specific 

skills

Placement 

Support

• Jobsite 

analysis

• Employer 

negotiation

• Assess 

accommodati

ons and 

assistive 

technology

• Coworker 

education

Employment 

Support

• Job coaching

• Selfadvocacy 

training

• Job retention 

and 

advancemen

t support

• Sometimes 

entrepreneur

ship
Settings 

HCBS waivers allow for 

employment services:

• Where an individual is 

employed

• In an agency setting

• In individuals’ homes

• In the community

• Sometimes, through work 

crews

States are relying less on:

• Facility-based settings 

• Specialized facilities not part 

of a general workplace

Source: (1) StateData: The National Report on Employment 

Services and Outcomes Through 2017 

6
Non-Work Services Still Dominate

7

Source: (1) StateData: The National Report on Employment Services and 

Outcomes Through 2017 
EMPLOYMENT SERVICE PROVISION 

PRE-COVID

8
Employment and Day Service Providers 

• Estimated 5,000 – 6,000 providers nationally1

– Mostly non-profit organizations:

▪ 85% non-profit, 6% for profit, 7% public (state or tribal), 2% 

other2

– Most were regional providers

▪ 51% county or regional scope, 36% local scope, 8% statewide, 

5% multi-state2

– Average operational budget (in 2014-15) $3.0 million2

– Average number of people served: 2192

– 60% were funded 51% or more by Medicaid or State IDD 

Agency

(2) Domin & Butterworth (2016): Research to Practice: The 2014-15 National Survey of Community Rehabilitation 

Providers Report 1: Overview of Services, Trends and Provider Characteristics

9
Providers specialized more in 

2014-15

10

Most community 

rehabilitation providers 

(CRPs) offer both supported 

employment and day 

services.

However, the number of 

CRPs offering each type of 

service fell between two 

survey rounds (2010-11 and 

2014-15), with the sharpest 

declines in non-work 

services.2
Hourly Rates are Most Common for 

Waiver Payments 

• 2017 review of Supported Employment in 1915(c) 

waivers3

• 183 out of 225 services paid using hourly rates

– Rest were daily (17 services), monthly (14 services) or other 

units (11 services) 

• Average hourly rate (projected) $29.00 

– Average daily rate $63.97, average monthly rate $458.56

– Wide variation in rates across states (and in service definitions)

• Average per participant spending (projected) $6,693 

• 51% of participants received fewer than 200 hrs of 

service annually

(3) Friedman & Rizzolo (2017), Journal of Vocational 

Rehabilitation, 46(1)107-116

11
EMPLOYMENT SERVICES UNDER 

PEAK SHELTER-IN-PLACE (SIP)

12
Shelter in Place Requirements make 

Far fewer settings available for Service

• HCBS waivers allow for employment services :

• Where an individual is employed – reduced access

• In an agency setting

• In individuals’ homes – largely remote

• In the community

• Sometimes, through work crews – may depend on 

sector (e.g. landscaping)

• Facility-based settings

• Specialized facilities not part of a general workplace

13
Services Under SIP

Only Remote Or 

Alternate Settings

Career Planning 

• Basic job skills 

• Vocational 

assessment and 

career planning

• Instruction on 

specific skills

• Filing for UI

• Skill maintenance 

on furlough

• Planning for safe 

reentry 

Placement Support 

• Jobsite analysis

• Employer 

negotiation 

• Assess 

accommodations 

and assistive 

technology

• Coworker 

education

Employment Support

• Infection control 

training

• PPE acquisition

• Job coaching 

possibly remote

• Self-advocacy 

training

• Job retention and 

advancement 

support

• Sometimes 

entrepreneurship

Very Limited

Depends on 

Employment

14
Percent who continued working after March 1

Preliminary data. Collected late May to June 2020

Data from 7 state SELN member states

Individual CIE n=8919

Group SE n=1922

15
Provider Response To Shelter-in-Place

• Individual jobs often continued

– Job coaches may not have been able to go into 

workplace 

– Some group homes would not allow people to work 

due to risk to others

• Many group-supported work programs 

closed 

• Some congregate work service programs 

got remote instruction and curricula in place

16
APSE: National Provider Survey –

Preliminary Findings 

• Surveys from 600 providers in 47 

states, collected mid-June

• 43% of agencies laid off or 

furloughed staff, expect 22% of 

jobs to be lost permanently 

• Closure of VR programs pushed 

more individuals into HCBS funded 

employment services

• Most agencies saw substantial job 

losses for people with disabilities, 

but many were able to support job 

seekers to fill positions in essential 

services 

17

SOURCE: APSE, “Impact of COVID-19 on Disability Employment 

Services and Outcomes: Preliminary Results from a National Provider 

Survey,” July 7, 2020. 
HCBS Waiver Appendix K

Adjustments For Employment Services

18

APPENDIX K COMPONENT (Specifying supported 

employment)

NUMBER OF 

STATES

Authorized retainer payments to supported employment 

providers

25

Implemented or expanded telehealth/electronic service 

delivery

23

Expanded settings where supported employment can be 

delivered

21

Changed payment rates or maximum number of hours 18

Allowed service limitations to be exceeded or services added 13

Allowed family caregivers 8
Challenges to Telehealth/Virtual 

Support

• Availability of technology

– Some state funding for participant technology

– Providers’ technology resources may also be limited

• Hard to replace 6-hour sessions via telehealth

– Career planning work typically billed for face-to-face time (job 

coaching may be hours “on behalf of” client) 

– Individual plan development is billable but not usually telehealth 

curriculum planning time

– Some states overtly supported, e.g. allowing day billing at lower 

threshold of contact time 

• Not all solutions are accessible

19
Silver linings! 

• Disruptions required individualized, person-centered 

responses 

• Pandemic is tipping the scales away from facilitybased programs, including day habilitation

• Maximizing use of technology increases individuals’ 

autonomy and independence 

• Anecdotally, greatest resilience among providers 

committed to choice and continued work

– May shift individuals among providers

– Resilience also baked into strategies such as self-direction

20
PROVIDER AND INDIVIDUAL

EXPERIENCES

➢ Values into Action – Pennsylvania

➢ Shared Support Maryland

21
VALUES INTO ACTION

Founded in 2005, Values Into Action is a network 

of organizations offering services and supports 

in partnership with people with disabilities, their 

families and other chosen allies, exclusively in 

their own homes, neighborhoods, workplaces and 

communities. No matter what the service, the 

person is in control and their preferences and 

aspirations drive and guide our actions.

Marian Frattarola-Saulino

Robert Zotynia

Pamela Zotynia

Kathy Perry

22
Rethinking Employment Services and Supports in the COVID-19 Era

Working is Essential!

Paz Margolis and Nahkita Evans ~ employer & employee mutual considerations 

on retaining and working together again

Kristi Culbreth ~ family owned business and the job coach relationship

Phillip Jones ~ meeting my needs and the expectations of my employer

Amanda Lay ~ ALL people can be essential workers

Mara Clawson ~ When Colors Get Along, virtual supports and staying in business 

Shared Support Maryland, Inc.’s Presenters would like to thank the U.S. 

Department of Health and Human Services, Administration for Community 

Living and Office of the National Coordinator for Health Information Technology 

for this fantastic opportunity.

Together they:

• Apply to juried shows (MOMA curator!)

o Discuss opportunities

o Write artists statements

o Communicate w/ clients

o Fulfill online orders

o Order supplies

• Mara created + delivered 2 commissioned 

artworks

• Mara’s business continues to thrive

o Profitable for past 4 years

Mara continues working with Rachel 

(job coach) via Skype
LOOKING FORWARD

26
CMS Guidance On Termination Of Covid-19 

Flexibilities (June 30 All State Call)

• Appendix Ks expire

– Limited to one-year approval

– Must end by March 31, 2021 

– States can elect an earlier date (which can be amended) 

• Most retainer payments limited to three 30-

day periods 

• Emergency IT funding does not expire

– No termination date for authority (not tied to public health 

emergency declaration)

27
Some Flexibilities Can Be Permanently 

Added To 1915(c) Waivers 

• Common changes that may be approved:

– Use of telehealth as appropriate for services 

– Assistive technology and other services that would be beneficial 

to the waiver population

– Retainer payments during absences from home/hospitalizations

– Rate increases to enhance provider pool

• Waiver changes can be submitted at any 

time, normal policies (including public notice) 

apply 

28
Ongoing COVID-19 Limitations

• Need for social distancing for foreseeable future

– Limits capacity in facility-based programs, increases per capita 

service delivery cost after re-opening

– Continuing need for telehealth approaches

• Increased costs to maintain safe workplace/service site

– PPE and infection control practices

– Physical space reconfiguration 

– DSP availability and skill set

• Reduced availability of public transportation

• Unemployment remains at 11.1% nationally, 49 states 

above 8.5%, 10 states between 15.1% and 25.3% 

29
Reopening – Connecticut Example 

• Underscored that workforce re-entry is a personcentered decision

– State surveyed individuals and families about interest, 

willingness and concerns

• All providers have to submit a reopening plan

– Plans need to include outreach to case managers to 

facilitate team meeting to develop a detailed plan for 

each individual (via telehealth)

– Incorporate a process to determine expectations of 

individual, family, and/or residential providers

SOURCE: “Reopening of Employment and Day Services,” Memo to DDS Providers from Jordan A. Scheff, Commissioner, 

June 10, 2020. https://portal.ct.gov/-/media/DDS/COVID19/DDS_Employment_and_Day_Services_reopening_memo_FINAL_6_10_20.pdf

30
Reopening – Connecticut Example 

• Phased reopening with enhanced payments for unbilled 

services

• Payment = Rate * (Billed units + Authorized unbilled * 

Utilization factor)

• Phase 1: Soft opening (expected July 15)

– Providers are to be available to support all DDS funded individuals with 

virtual face-to-face supports for at least 1 hour of service at least 3 days 

per week 

– Providers need to support at least 50% of individuals in their agencies for 

at least 50% of their weekly service hours

– Providers could plan for fewer individuals served due to physical space 

limitations and/or individuals’ unwillingness to participate (utilization 

adjustment capped)

• Phase 2 (~Sept 1, depends on benchmarks) 50% → 75%, 

utilization factor falls

• Phase 3 (~Oct 1, depends on benchmarks) 75% → 100% 

31
CAN THIS BE AN OPENING TO 

REINVENT SERVICES? 

32
Support Flexibility, Promote 

Outcomes 

• Expand allowable costs to best meet 

participants’ needs

– Ongoing use of telehealth

– Technology acquisition – including provider infrastructure

– Individualized curriculum planning for telehealth

• Tie limits on selected services (e.g. job 

development) to external conditions 

– Reopening phases 

– Potentially unemployment rates (but don’t change too 

often)

33
Support Flexibility, Promote 

Outcomes 

• Facilitate natural supports in the workplace

– Wisconsin “Partners with Business” Ongoing use of telehealth

– Technology acquisition – including provider infrastructure

– Individualized curriculum planning for telehealth

• Tie limits on selected services (e.g. job 

development) to external conditions 

– Reopening phases 

– Potentially unemployment rates (but don’t change too often)

34
Support Flexibility, Promote 

Outcomes 

• Rate models could provide predictability under 

changing circumstances

– Hybrid service rates that allow for mix of face-to-face and 

remote

– Per member per month case rates (would need worked 

through with CMS)

▪ Need guardrails to ensure appropriate levels of services

▪ Adjustments for level of need – could be for entire portfolio

▪ May need tiers, for example by number of hour participants 

works

– Allow for experimentation in exchange for outcomes...

35
Support Flexibility, Promote 

Outcomes 

• Unlike many IDD services, Supported 

Employment has a clear observable outcome 

(“Real work for real pay in the real world”)

• Competitive Integrated Employment (CIE) is 

multidimensional: wages, hours worked, 

length of retention, benefits

• May also want to promote (limited) key preemployment milestones (e.g. resume building)

36
Support Flexibility, Promote 

Outcomes 

Outcomes can be promoted through:

• Incentive payments/bonuses

– California both pays incentives at 30 days, 6 months, and 12 

months of employment, as well as incentives for paid internships

• Rates that incentivize 

– Community based over facility based

– Employment over pre-employment

– Fade out/time limits 

• Payment/service structures that also promote:

– Access to ancillary services such as non-medical transportation 

to/from work

– Use of non-provider workplace supports

37
Wisconsin “Partners with Business” 

38

For More 

information:

https://acl.gov/progr

ams/youthtransitions/partners

hips-integratedemploymentsystem-changegrants

https://www.letsgett

oworkwi.org/index.p

hp/partners-withbusiness-toolkit/
Outcome Based Payment 

Challenges 

• Systems need to account for acuity levels to promote 

inclusion of all individuals

• Complex and/or unpredictable payment structures 

can be difficult for providers to manage

– These may preference larger providers with more sophisticated 

back offices

• Ideal for CMS might be risk-sharing, but IDD systems 

aren’t there yet

• Individuals have multiple goals 

– E.g. May also want to encourage participation in non-work 

community activities outside work hours

39
Ideal Strategies Leverage All Funding

40
Duane Shumate, 

Director of Youth Transition/Employment, Missouri Department of 

Mental Health Division of Developmental Disabilities

EXAMPLE: MISSOURI VBP MODEL IN 

DEVELOPMENT

41
VBP Model for Supported Employment Services 

(SES): Changes to Service Definitions

42

Divide Career Planning into 2 

Phases

Exploration

Discovery

Divide Job Development into 2 

Phases

Draft plan for identifying and negotiating job 

opportunity for waiver participant

Implementation of plan that leads to participant 

attaining a job in competitive, integrated 

employment

Create new service definition – Benefits Planning

Consider the following additional 

service definition changes:

Eliminate distinction in individual/group 

prevocational services, and replace with a 

“community-based” prevocational services and 

one “facility-based” prevocational services
VBP Model for SES: Suggested VBP Individual 

Milestone & Provider Incentive Payments

Milestone Payments

• Career Planning – Exploration

• Career Planning – Discovery

• Job Development – Plan

• Job Development – Securement

Incentive Payments

• Transition of Waiver Participant from 

Prevocational to SES

• Transition of Waiver Participant from 

Group SES to Individual SES

• Provider forfeits Section 14(c) special 

wage certificate

• Provider Assures Specialized 

Training Requirements are completed 

for DSPs doing career planning, job 

development & SES

43
3

Tier all payments for 

Career Planning, Job 

Development and 

Individual Supported 

Employment Services 

by Acuity

Levels 1-2: High 

Acuity, Low 

Support Needs; 

10% reduction in 

Base Unit Rate

Levels 3-5: 

Medium Acuity & 

Support Needs; 

Base Unit Rates

Levels 6-7: Low 

Acuity, High 

Support Needs; 

10% reduction in 

Base Unit Rate

Tie Career Planning & 

Job Development 

Milestone Payments to 

completion of specific 

reports for data 

collection & tracking

Exploration: 

Combined 

Information Intake & 

Observational 

Summary

Discovery: 

Job-Seeker/ 

Personal 

Employment Profile 

Job Development: 

Job Development 

Plan 

Job Placement: 

Job Placement Form 

and Job Placement 

Checklist

Create Faded Job 

Coaching Support 

Model that 

incentivizes gradual 

fading of supports

Allow providers to 

bill for only certain 

percentage of 

hours participant 

works based on 

acuity; decreased 

rate over time

Allow providers to 

bill at 1⁄2 base unit 

rate for faded hours 

of support for 6 

monthsThen allow 

providers to bill 1⁄4 

base unit rate for 

faded hours of 

support for 

additional 6 months

Revise base unit rates 

for the following 

services to assure that 

group/facility-based 

services are not 

financially 

advantageous

Day 

Habilitation

Group SES

Prevocationa

l (Individual 

and Group)

Implement OneTime Incentive 

Payments to 

Reward 

Transformative 

Actions

Let go of 14(c) 

special wage 

certificate

DSP Training in 

Promising 

Practices

% Reduction in 

Facility-Based 

Day or 

Prevocational 

Services

Implement Outcome 

Payments based on 

Quarterly Outcomes 

reported at individual 

level by provider

Transition to 

Individual 

SES

Ranges of 

Hours 

Worked

Wages

Benefits

Length of 

Duty

Open ABLE 

Acocunt

VBP Model for SES: 

Suggested Multi-Tiered Strategy
Q & A

AND 

DISCUSSION 

45
What’s Next?

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a panelist, email AOD@acl.hhs.gov

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about this webinar 

46