Living Well 2020 

Cross-Site Evaluation

Volume II 

Grantee Profiles
Table of Contents

3 Alaska

8 Georgia

13 Idaho

18 Indiana

23 Missouri

28 New Hampshire

33 Virginia

38 Wisconsin

Graphics Legend

Each grantee’s model addresses eight Key Features specified in the funding opportunity announcement for Living Well grants. 

The Key Features addressed by each activity within the models are noted in the profiles using the icons in Exhibit 1.

Exhibit 1. Eight Key Features of Living Well Models 

Partnerships Meaningful and active 

engagement with selfadvocates and families

Evidence based 

practices for service 

improvements

Building capacity 

of DSPs and HCBS 

providers

Reducing abuse 

and neglect through 

community monitoring

Addressing health and 

safety with data tools

Program and 

outcome evaluation

Sustainability
Living Well Annual Report Volume II: Grantee Profiles 3

ALASKA

Living Well Grantee Profile

The Alaska Governor’s Council on Disabilities and Special Education (the Council) received the five-year Living Well grant 

in 2018.

I. Grantee Information

The Council, started in 1975, comprises 26 members and serves a variety of state and federal roles. These include acting 

as the State Council on Developmental Disabilities (DD), the Interagency Coordinating Council for Infants and Toddlers 

with Disabilities, Alaska’s Special Education Advisory Panel, and as the governing board for the Special Education Services 

Agency. The Council is organized with multiple committees, each of which is chaired by a Council member. 

The organization works towards systems change in areas including early intervention, independent living, inclusion in the 

community, education, employment, health, and self-directed lives with meaningful choices. The Council oversees a variety 

of initiatives in projects to improve the lives of people with disabilities in Alaska. These include emergency preparedness 

activities, including development and distribution of toolkits; supported decision-making agreements, which give people 

the help they need to make choices about their lives; and self-employment grants, which are available to qualifying people 

with disabilities.

II. Grantee Partnerships

The Council partners with key stakeholders on their Living Well grant (collectively, the Alaska Living Well team) including, 

but not limited to, the Alaska Association on Developmental Disabilities, Disability Law Center of Alaska, State of Alaska 

Senior and Disability Services, and the University of Alaska Anchorage Center for Human Development.
Living Well Annual Report Volume II: Grantee Profiles 4

III. State Context

Variations in access to quality home and community-based services (HCBS) occur, in part, due to varying demographic, 

economic, political, and historical factors in each state. Key contextual factors are described here to better understand the 

Council’s external conditions for their Living Well model. The COVID-19 pandemic rapidly evolved during the 2019-2020 

evaluation cycle with significant impact on the delivery of HCBS and the health and safety of individuals with intellectual 

and developmental disabilities (I/DD). The pandemic response influenced both how and the extent to which grantees 

implemented grant activities as planned and the local and state context in which the grant is being implemented.

In Alaska, there are consistent challenges with the state budget, and budget uncertainty was exacerbated by COVID-19. The 

Alaska Living Well team anticipates more budget cuts, especially with the impact of COVID-19 on the tourism industry, 

which accounted for more than $126 million in state revenues and $88 million in municipal revenues in 2018.1 Revenue 

generated from tourism is used to fund services across the state, including services for people with disabilities. To mitigate 

this budget issue, the Alaska Living Well team continues to provide recommendations for cost savings to state agency 

leadership.

Several efforts to improve access to and quality of HCBS in Alaska are delayed. While implementation of some plans is 

delayed and impacted by budget cuts, Alaska Living Well staff are optimistic that a continued focus on person-centered care 

will increase awareness that individuals can direct their own plans. 

1 Alaska Resource Development Center. (2020). Alaska’s Tourism Industry. Retrieved from https://www.akrdc.org/tourism.
Living Well Annual Report Volume II: Grantee Profiles 5

IV. Model and Objectives

The Alaska DD Systems Collaborative, comprised of stakeholders from across the state, developed a shared vision statement 

for the DD system in Alaska: “Alaskans share a vision of a flexible system in which each person directs their own supports, 

based on their strengths and abilities, towards a meaningful life in their home, their job and their community. Our vision 

includes supported families, professional staff and services available throughout the state now and into the future.” 

The Alaska Living Well team aligned their Living Well objectives with the DD systems shared vision to most effectively 

impact change in parallel with other systems work. In order to build towards system alignment with the vision, the Alaska 

Living Well team is working with stakeholders to target three groups: individuals with I/DD and their families, service 

providers, and policymakers. These three groups provide valuable insight to inform best practices for systems alignment 

and priority setting.

The Alaska Living Well team’s model objectives are to:

1. Enhance the health and safety of individuals who experience developmental disabilities by increasing their 

independence, self-determination, community integration, employment, and participation;

2. Strengthen the knowledge and skills of direct support professionals (DSPs) to use evidence based and/or promising 

practices related to culturally and linguistically person-centered thinking and supported decision-making which may 

improve workforce stability, retention, and advancement;

3. Strengthen and elevate the leadership roles that self-advocacy organizations, Centers for Independent Living, and 

other peer support networks, working together with families and others, play in improving and assuring the quality 

of HCBS; and

4. Enhance the effectiveness and coordination efforts by the state, the DD Act network and others to implement 

the HCBS settings rule and address rights violations in the HCBS delivery system for people with developmental 

disabilities.

V. Key Activities by Core Components

A. Community Monitoring

Community Monitoring includes efforts to develop a comprehensive system to monitor the health and well-being of 

individuals with I/DD living in a variety of home and community-based settings. The following are key activities reported 

by the Alaska Living Well team during this evaluation period to address this core component: 

Key Activity: Use National Core Indicators (NCI) Survey Data

• Alaska received approval to add questions to their NCI survey to gauge the person-centeredness or persondirectedness of the existing emergency plans and ensure that emergency plans reflect the needs of individuals. 

• The Alaska Living Well team is participating in a pilot from NCI to complete a remote version of the NCI survey to 

determine if remote administration of the survey is viable.

Key Activity: Conduct DD Systems Alignment Survey

• In collaboration with the Alaska University Center for Excellence in Developmental Disabilities, University of Alaska 

Anchorage Center for Human Development (Alaska UCEDD) and the DD Collaborative, the Alaska Living Well team 

developed a new survey designed to measure the state’s overall DD systems alignment to the vision. One version of the 

survey is specific to individuals with I/DD and uses plain language; the other version is specific to family members, 

providers, and other stakeholders with more detailed language. Baseline data from the survey included responses from 

48 self-advocates and 69 other stakeholders. 
Living Well Annual Report Volume II: Grantee Profiles 6

B. Community Capacity Building

Community Capacity Building includes efforts to increase the skills and knowledge of all individuals, families, and service 

providers in the HCBS system. The following are key activities reported by the Alaska Living Well team during this 

evaluation period to address this core component: 

Key Activity: Participate in 2020 Key Campaign

• The Alaska Living Well team collaborated with self-advocates and other stakeholders to develop four documents for 

Alaskan legislators as part of the 2020 Key Campaign in Juneau. The Alaska Living Well team and other grant partners 

also produced a webinar series focused on supporting self-advocates ahead of the Key Campaign legislative visits and 

ensuring an in-depth understanding of the DD shared vision. Following the webinar series, and as part of the Key 

Campaign, self-advocates created a DD shared vision brochure for dissemination to policymakers.

Key Activity: Implement a Series of DSP 

Trainings and Capacity Building Activities 

• The Alaska Living Well team continued to work with the Alaska UCEDD and the statewide DD service provider 

organization on capacity building efforts with Alaska’s DD providers and their DSPs. The Alaska UCEDD has expertise 

in innovative training delivery models focused on reaching rural and remote regions of the state, which is valuable to 

the grant team as they seek to share vital information rapidly statewide during the pandemic. As part of these efforts, 

the teams will implement trainings that will be aligned with the DD shared vision and co-led by self-advocates.

• The Alaska Living Well team and the Alaska UCEDD also developed and implemented an additional training module 

for DSPs and care coordinators. The training, which was also developed to be user-friendly for use by families, 

focuses on blending paid and unpaid supports for individuals strengthening their ability to live meaningful lives 

through community integration. The training was delivered through three webinars, which each had an average of 92 

registrants.

• The Alaska Living Well team partnered with the Alaska UCEDD to increase cultural and linguistic competence 

among Alaska’s DSP workforce. The Alaska UCEDD contracted with the National Center on Linguistic and Cultural 

Competency to develop and deliver a four-part webinar series training. The training was designed to help Alaskan 

organizations and leaders identify ways to increase the cultural and linguistic competence of their services to 

individuals with I/DD and their families.

Key Activity: Implement Community Relationship Building Program Pilot

• The Alaska Living Well team collected feedback from the pilot cohort of the Community Relationship Building 

Program, a pilot funded by and existing within the Hope Community Resources, a provider agency. The pilot included 

training for all supervisors and DSPs at Hope Community Resources to understand the key concepts of support and 

how implementation supports meaningful lives. Pilot participants reported satisfaction with engagement and content.

Key Activity: Plan Supported Decision-Making 

Agreements Communication Pilot 

• The Alaska Living Well team continued to plan the Supported Decision-Making Agreements (SDMA) Communication 

Pilot with Arc of Anchorage and Adult Protective Services, and ATLA, the assistive technology agency for the 

state, to improve first-person fact reporting to state agencies. The pilot design will assess the accuracy of receptive 

communication among individuals who use assistive technology or a supporter for communication. SDMAs outline 

a description of a supporter’s assistance. The expected outcomes of the pilot are recommendations for policies, 

procedures, and training on effective communication with people who use supports and SDMAs.

• The Alaska Living Well team continued to share best practices around SDMAs nationally. As part of this effort, the 

team provided resources from Alaska’s experiences. Alaska’s work was highlighted in two American Bar Association 
Living Well Annual Report Volume II: Grantee Profiles 7

Commission on Law and Aging reports.2, 3

• During this reporting period, there were 17 SDMAs in Alaska with five in the queue. The SDMAs are expected to 

live beyond the Living Well grant period, and the Alaska Living Well team is exploring ongoing funding strategies to 

continuing developing SDMAs. The Alaska Living Well team will develop a toolkit based on findings from the pilot, 

which will broadly support agencies communicating with people with disabilities.

Additional Activities:

• Partner with Peer Power Alaska: The Alaska Living Well team supported Peer Power Alaska, a statewide self-advocacy 

group, in facilitating monthly webinars with self-advocates and care coordinators and planning the annual SelfAdvocacy Summit.

• Develop HCBS Plan of Care Training Framework: The Alaska Living Well team developed a training framework, 

which included person-centered emergency plans and goals around health, safety, and employment, to enhance the 

HCBS waiver plan of care process. The team offered four webinars online during summer 2020.

• Disseminate Employment Handbook: In partnership with the Division of Vocational Rehabilitation (DVR), the 

Alaska Living Well team disseminated 3,000 copies of the Alaska Transition Handbook: Pathway to Adulthood and 

Employment to all 54 school districts statewide.

VI. Analysis and Conclusion

A. Contextual Factors

As with many other states, the impact of COVID-19 changed the way the Alaska Living Well team executed their Living 

Well activities. Alaska is a state consistently affected by budget cuts, and the pandemic presented even more competing 

priorities for state agency funding. The team’s ability to remain proactive, partially due to their experience with budget 

restraints in the past, enabled them to efficiently provide recommendations for cost-savings in other areas to ensure critical 

services remain intact. These skills transcend the Living Well grant and offer promise for funding security even after the 

grant ends. 

B. Model Design

The existing Alaska DD Systems Collaborative brings together a variety of key stakeholders; the Alaska Living Well team 

directly benefits from this group and may facilitate Living Well initiatives and goals through an existing infrastructure 

as opposed to creating a new one. In addition, the distinct focus on systems alignment via the shared vision serves as a 

direct mechanism for long-term impact. By focusing on engagement of individuals with I/DD and their families, service 

providers, and policymakers, the Alaska Living Well team maximizes the spread of information on Living Well grant 

activities, facilitates a platform to achieve grant objectives, and builds towards the agency alignment goal. 

C. Key Activities

The Alaska Living Well team implements activities that are designed with person-centeredness and lived experience 

in mind, with consistent engagement of self-advocates and family members. The Alaska Living Well team facilitates 

systems change from the ground up by providing self-advocates a platform to share their goals and any areas of need with 

providers, care coordinators, and policymakers. The Alaska Living Well team also aims to lay the groundwork for longterm change, including through policy recommendations, resource development, and other capacity building efforts. To 

support scalability and sustainability, the team documents best practices and holds conversations with other agencies 

to secure additional funding post-Living Well grant. As a whole, the Alaska Living Well team implemented a variety of 

activities to measure progress, expedite cross-systems collaboration, and ultimately impact the HCBS system. These in 

turn influence key stakeholders’ decisions and align outcomes with goals to support people with disabilities in achieving 

meaningful lives.

2 American Bar Association (2020). Supporting Decision-Supports Across the Age Spectrum: Final Report. Retrieved from https://www.americanbar.org/content/ dam/aba/administrative/law_aging/2020-supporting-decision-making-final-report.pdf.

3 American Bar Association (2020). Supporting Decision-Supports Across the Age Spectrum: Supplemental Materials. Retrieved from https://www.americanbar. org/content/dam/aba/administrative/law_aging/2020-decision-supports-forums-supplemental-materials.pdf.
Living Well Annual Report Volume II: Grantee Profiles 8

GEORGIA

Living Well Grantee Profile

The University of Georgia Institute on Human Development and Disability (UGA IHDD) received the five-year Living Well 

grant in 2017.

I. Grantee Information

The UGA IHDD was established and has been a part of the University Center for Excellence in Developmental Disabilities 

Education, Research, and Service network since 1969. The UGA IHDD works to create opportunities to improve the quality 

of life for people with disabilities and their families through education, research, and public service. Areas of focus include 

assistive technology, employment, friendships and community membership, family support, human rights, and research 

and evaluation.

The UGA IHDD provides a range of supports and services through various projects, including Living Well. Other projects 

include AgrAbility, which focuses on promoting independence for members of the agricultural community who have 

disabilities; Advancing Employment, which is dedicated to making Georgia a community for inclusive employment; Take a 

Look at MeTM and Welcome to My WorldTM, which are interactive portfolios designed to engage individuals and/or family 

members as they identify strengths, interests, and preferences; and efforts to implement policy, including support of the 

HCBS Settings Rule.

II. Grantee Partnerships

The UGA IHDD partners with key stakeholders on their Living Well grant (collectively, the Georgia Living Well team) 

including, but not limited to, the Georgia Advocacy Organization, Georgia Council on Developmental Disabilities, Georgia 

Department of Behavioral Health and Developmental Disabilities, and People First of Georgia. 
Living Well Annual Report Volume II: Grantee Profiles 9

III. State Context

Variations in access to quality home and community-based services (HCBS) occur, in part, due to varying demographic, 

economic, political, and historical factors in each state. Key contextual factors are described here to better understand UGA 

IHDD’s external conditions for their Living Well model. The COVID-19 pandemic rapidly evolved during the 2019-2020 

evaluation cycle with significant impact on the delivery of HCBS and the health and safety of individuals with intellectual 

and developmental disabilities (I/DD). The pandemic response influenced both how and the extent to which grantees 

implemented grant activities as planned and the local and state context in which the grant is being implemented.

Georgia elected a new Governor in 2019, which brought new leadership and priorities to the Department of Behavioral 

Health and Developmental Disabilities (DBHDD). In the wake of the COVID-19 pandemic, a new budget was signed into 

law as of June 30, 2020 that included significant budget cuts, the highest percentage of which were attributed to DBHDD. 

These cuts to the agency largely impact services for adults with DD, as well as child and adult mental health services.

Additionally, the participating provider agencies have experienced turnover at all levels, but particularly within mid-level 

management. This included many people who were trained to implement Therap, an electronic documentation system 

for people with intellectual disabilities, and staff members who were responsible for drafting one of the Georgia Living 

Well team’s training interventions. While the full impact is still unknown, the team anticipates challenges to their planned 

approach to examine the impact of staff training on individual outcomes due to provider agency closures and staff turnover 

due to COVID-19.

Despite state budget challenges, the Georgia Living Well team has a strong working relationship with DBHDD. The number 

of vacancies among direct support professional (DSP) staff within provider agencies is high, with the more progressive 

models of support being the most challenging. Leadership from DBHDD are working with UGA IHDD to address 

provider recruitment and retention issues within Georgia. Leadership from DBHDD also expressed willingness to support 

a proposal for increased funding for state DD services, and they asked the Georgia Living Well team to convene a group of 

stakeholders to identify and propose one key need to propose to state legislature.
Living Well Annual Report Volume II: Grantee Profiles 10

IV. Model and Objectives

The Georgia Living Well team is working to improve outcomes for individuals with I/DD receiving support by targeting 

interventions to the direct support workforce. In order to achieve this, the Georgia Living Well team partnered with five 

providers to implement training and monitoring using the College of Direct Support (CDS) and Therap platforms. 

The Georgia Living Well team’s model objectives are to:

1. Increase staff knowledge and skill in supporting people with I/DD to be self-determined and included in the 

community through targeted training in Supporting Informed Decision-Making and Supporting Social Roles;

2. Create career paths through professional development for direct support staff to meet demand for services through 

the implementation of Direct Course’s CDS and engagement with the National Alliance for Direct Support 

Professionals;

3. Enhance monitoring using Therap’s electronic service tracking and reporting technologies including their Business 

Intelligence platform for data aggregation and trending; and

4. Develop a replicable collaboration between HCBS stakeholders to enhance quality.

V. Key Activities by Core Components

A. Community Monitoring

Community Monitoring includes efforts to develop a comprehensive system to monitor the health and well-being of 

individuals with I/DD living in a variety of home and community-based settings. The following are key activities reported 

by the Georgia Living Well team during this evaluation period with the main goal of addressing this core component: 

Key Activity: Collect and Analyze Data using Therap

• Therap is a secure, HIPAA-compliant, and comprehensive electronic monitoring system for HCBS providers. It 

allows for the consistent and standardized documentation of incident reporting, medication management, goals, and 

outcomes. Each of the five participating provider organizations use Therap. The Georgia Living Well team analyzed the 

data across all providers to identify trends and determine the impact of their interventions.

• The Oracle Business Intelligence (BI) platform has multiple dashboards that can produce real time ad-hoc reports in 

Therap. The Georgia Living Well team primarily uses two dashboards in the BI platform: Data Driven Outcomes and 

General Event Reporting. 

• The Data Driven Outcomes dashboard allows for large scale data aggregation and assessment of outcomes across 

two measurement types (Important To and Important For) and five domains: Safety, Health and Wellbeing, 

Social Connectedness and Relationships, Meaningful Activities, Person-Centered Planning, and Choice. 

• The General Event Reporting dashboard, where incident reports and adverse incidents data are collected, allows 

for summary and longitudinal analyses of adverse incidents at all levels of organizations. The dashboard also 

has the capacity to input existing state level data to support comparative analyses. Providers enter day-to-day 

service data that are distributed to the internal quality assurance team. Raw data can be filtered and analyzed 

to look at incidents by program, the types of incidents occurring, and the number of incidents per individual. 

This information will help the Georgia Living Well team better understand how to allocate resources as well as 

identify which individuals in the system require special attention. In response to COVID-19, Therap created 

a portal for users within the General Event Reporting that hosts resources for responding to COVID-19 and a 

means for tracking COVID-19 cases.
Living Well Annual Report Volume II: Grantee Profiles 11

B. Community Capacity Building

Community Capacity Building includes efforts to increase the skills and knowledge of all individuals, families, and service 

providers in the HCBS system. The following are key activities reported by the Georgia Living Well team during this 

evaluation period to address this core component: 

Key Activity: Implement Training 

through the College of Direct Support 

• The CDS is a platform that hosts a range of courses and training programs targeted at providers and DSPs. The 

Georgia Living Well team is working closely with five local provider agencies to develop three tracks in CDS for staff: 

new hire track, existing staff track, and the frontline supervisor track. In addition to the development of these tracks, 

the providers created several of their own modules, including: Behavioral Supports and Crisis Intervention, PersonCentered Planning, Community Inclusion, Crisis Prevention, and Documentation of Fire, Safety, and Evacuation. 

The DSPs and other agency staff began CDS courses on October 1, 2018, and the Georgia Living Well team regularly 

monitors the number of courses completed and modifies trainings as necessary based on feedback.

• The CDS includes on-the-job assessments measure the extent to which individuals enrolled in a course can 

demonstrate what they have learned in daily practice.

Key Activity: Implement Supporting 

Informed Decision-Making Training

• The Georgia Living Well team, with the support of an assistant trainer, delivered Supported Informed DecisionMaking trainings in-person to DSPs and frontline supervisors two years consecutively. The purpose of these trainings 

is increase staff knowledge and skills in supporting individuals with I/DD to be self-determined and included in the 

community. Through these trainings, staff of participating organizations learn how to support individuals with I/DD in 

achieving personal goals related to choice, independence, community integration, and productivity. At the end of each 

training, the team conducts an evaluation and then refines the training based on feedback. This process ensures that 

the training remains beneficial and relevant for the staff.

Key Activity: Implement Supporting Social Roles Training 

• The Supporting Social Roles training was delivered in-person to DSPs and focused on what social roles are, how social 

roles can be supported, and how these roles can support community inclusion. The training walks the DSP through the 

person-centered process of identifying and filling social roles of individuals with I/DD in the community. Additionally, 

the training provides strategies DSPs can use to make and sustain community connections for the people that they 

serve.

Key Activity: Conduct Annual DSP Staff Survey 

• Each year, the Georgia Living Well team distributes a survey among the five provider partners that assesses the type 

and nature of services provided, participation in staff training, staff retention and turnover rates, and staff pay, bonuses, 

and incentives. Data are analyzed annually, and key trends are identified and shared with the provider agencies.
Living Well Annual Report Volume II: Grantee Profiles 12

VI. Analysis and Conclusion

A. Contextual Factors

Changes in leadership within the state of Georgia prompted new priorities among agencies, and COVID-19 only 

exacerbated challenges posed by these changes. The resulting budget alterations pushed UGA IHDD to reassess how 

their provider partners most effectively deliver services to individuals with I/DD, particularly given the magnitude of 

staff turnover over the past several months. The willingness of DBHDD to rally behind UGA IHDD’s work, however, is a 

promising practice that sets a precedent for the Georgia Living Well team’s work in the state. The agency’s enthusiasm to 

support future funding and address provider retention issues marks an opportunity for future collaboration on initiatives 

that support the Georgia Living Well team’s objectives.

B. Model Design

The Georgia Living Well team works closely and collaboratively with five provider agencies within the state to understand 

the current landscape of the direct support workforce. Through their partnerships, the team has been able to distribute 

a number of tools and resources to direct support staff to create sustainable career paths and support professional 

development. Self-advocates and family members are also represented in Georgia Living Well teams to ensure a lived 

experience is reflected in project activities, thus putting more resources into the most relevant areas of need.

C. Key Activities

Efforts to support providers yield positive results for people with disabilities in the state. Providers have various 

opportunities to provide feedback on project activities, which ensures adequate content is offered and providers leave 

with tangible skills to impact systems change. Beyond these feedback mechanisms to inform training improvements, the 

Georgia Living Well team utilizes reporting tools to track and analyze critical incidents. Monitoring incidents, identifying 

trends, and providing subsequent data driven recommendations informs best practices for sustainability and scalability 

beyond the Living Well grant. Overall, the Georgia Living Well team uses a multitude of reporting strategies to achieve 

Living Well goals and implement related practices across stakeholder groups to ensure continuation of Living Well values 

even after the grant ends.
Living Well Annual Report Volume II: Grantee Profiles 13

IDAHO

Living Well Grantee Profile

The University of Idaho Center on Disabilities and Human Development (CDHD) received the five-year Living Well grant 

in 2018.

I. Grantee Information

The University of Idaho CDHD, Idaho’s University Center for Excellence in Developmental Disabilities Education, 

Research, and Service, facilitates a variety of independent grant programs and provides training, services, technical 

assistance, research, and dissemination activities across on a state and federal level. The organization uses education, 

outreach, research, and service to advance evidence based policy and practice for people with disabilities. The activities that 

CDHD participates in span five areas, which include interdisciplinary training and preparation of students, direct services 

and demonstration projects, community training and technical assistance, research, and dissemination of information and 

findings. 

Idaho CDHD’s projects include the Idaho Assistive Technology Project, which is a federally-funded program that aims to 

increase the availability of assistive technology devices and services for people with disabilities; IdahoSTARS, a statewide 

program designed to assist parents by offering child care referrals and information about quality child care settings; and the 

Idaho Training Clearinghouse, an initiative to compile all current special education-related trainings statewide in order to 

connect educators and parents with cross-agency training opportunities. 

II. Grantee Partnerships

The CDHD partners with key stakeholders on their Living Well grant (collectively, the Idaho Living Well team) including, 

but not limited to, the Idaho Council on Developmental Disabilities, Disability Rights Idaho, and the Idaho Department of 

Health and Welfare.
Living Well Annual Report Volume II: Grantee Profiles 14

III. State Context

Variations in access to quality home and community-based services (HCBS) occur, in part, due to varying demographic, 

economic, political, and historical factors in each state. Key contextual factors are described here to better understand 

CDHD’s external conditions for their Living Well model. The COVID-19 pandemic rapidly evolved during the 2019-2020 

evaluation cycle with significant impact on the delivery of HCBS and the health and safety of individuals with intellectual 

and developmental disabilities (I/DD). The pandemic response influenced both how and the extent to which grantees 

implemented grant activities as planned and the local and state context in which the grant is being implemented.

At the end of 2019, the Governor’s office requested that state agencies hold back one percent of their budget for the year, 

and two percent the following year. The request comes from a decrease in state revenues. The Department of Health and 

Welfare’s services were cut back due to the state funding cuts, and the Governor announced another five percent cut in the 

spring of 2020. While the cuts have not inhibited the Idaho Living Well team’s work to date, they do impact the areas that 

the grant is trying to affect. Conversations about sustainability are in progress. 

The K.W. vs. Armstrong lawsuit continues to be a factor that affects work in the I/DD field in Idaho, and the timelines 

for the class action suit are pending modification. The impact on the Idaho Living Well team is mostly manifested in 

how much the Department of Health and Welfare staff participate in grant activities. The state requested an extension 

on the lawsuit that, if approved by the court, will extend the state’s focus on the lawsuit. The lawsuit was filed to develop 

a new resource allocation model because the previous algorithm lacked transparency. Community NOW! (CNOW!) is a 

statewide collaborative convened in January 2017 in response to the lawsuit for adults with I/DD and family members to 

lead discussions about services provided under Idaho’s Medicaid HCBS waiver program. Team members from CNOW! 

developed a set of recommendations for the Department of Health and Welfare and state legislators. 
Living Well Annual Report Volume II: Grantee Profiles 15

IV. Model and Objectives

Idaho CDHD’s Living Well grant objectives aligned with CNOW!’s recommendations, and the grant provided an 

opportunity to build on CNOW!’s momentum to advance the recommendations. The Idaho Living Well team, in 

partnership with CNOW! and other stakeholders, established a series of workgroups to implement key grant activities. 

The Idaho Living Well project aims to build a self-advocate led monitoring system and build provider capacity through a 

career pathway that includes evidence based approaches to help individuals with I/DD advocate for their own lives.

The Idaho Living Well team’s model objectives are to:

1. Develop a nationally relevant, replicable work plan via a continuous improvement process carried out through 

project workgroups and monitored by the project leadership team;

2. In partnership with people with disabilities, create a single, integrated, community-based reporting and monitoring 

system that reduces risk to people with disabilities who have experienced abuse, neglect and exploitation;

3. Develop a sustainable self-advocate train-the-trainer model conduct statewide training on how and when to report 

abuse, neglect and exploitation, self-advocacy, individual rights, principles of person-centered thinking, selfdetermination, supported decision-making, and post-secondary employment, education opportunities, and cultural 

competency;

4. Establish a comprehensive career pathway for direct support staff guided by evidence based practices aligned with 

principles of self-determination and person-centered thinking;

5. Deliver sustainable, accessible training for direct support staff taught by self-advocates, family members and 

professionals guided by evidence based practices in person-centered thinking and planning, trauma informed care, 

supported decision-making, total and functional communication, and principles of positive behavioral intervention 

supports; and

6. Develop a culturally and linguistically competent adult DD service system for the Latinx community in Idaho.

V. Key Activities by Core Components

A. Community Monitoring

Community Monitoring includes efforts to develop a comprehensive system to monitor the health and well-being of 

individuals with I/DD living in a variety of home and community-based settings. The following are key activities reported 

by the Idaho Living Well team during this evaluation period to address this core component: 

Key Activity: Analyze Abuse and Neglect Reporting System

• The Idaho Living Well team formed a Quality Assurance Abuse and Neglect Reporting and Monitoring Workgroup 

with key stakeholders across the state. The goal of this workgroup is to protect individuals with disabilities from, and 

ultimately prevent, abuse, neglect, and exploitation by creating a self-advocate informed, integrated, community-based 

reporting and monitoring as a component of a larger quality assurance system.

• One activity under this workgroup is the development of a caregiver misconduct registry. This registry would be would 

be a single repository that contains all reports of abuse against staff working for Medicaid providers, and would be 

publicly available for self-advocates and providers looking to hire staff.

• To fully understand the abuse and neglect reporting system within Idaho, the workgroup conducted an activity in 

which each stakeholder mapped their complaint response system from beginning to end, and the workgroup then 

analyzed each system to see where the different systems intersected and where there were gaps. From this mapping 

exercise, the Idaho Living Well team created a spreadsheet of the reporting processes within the state and distributed it 

among the stakeholders.
Living Well Annual Report Volume II: Grantee Profiles 16

B. Community Capacity Building

Community Capacity Building includes efforts to increase the skills and knowledge of all individuals, families, and 

service providers in the HCBS system. The following are key activities reported by the Idaho Living Well team during this 

evaluation period to address this core component: 

Key Activity: Promote Diversity, Inclusion, and Cultural Competency

• The Idaho Council on Developmental Disabilities and the advocacy group Las Señoras assembled the Culturally 

Responsive Advisory Group (CRAG) workgroup with five self-advocates and five parent advocates from the Latinx 

community. The CRAG has fully integrated with the Idaho CNOW! workgroup and represents the needs of the Latinx 

I/DD community. The CRAG and CNOW! work closely together to ensure diversity and inclusion in team meetings, 

share Spanish language materials and resources, and disseminate other tools to support participation of Spanishspeaking individuals in virtual settings (e.g., Zoom tutorials, Spanish interpreters).

• To increase the level of cultural competency and knowledge among providers and Department of Health and Welfare 

staff, the Idaho Living Well team scheduled a cultural competency training with Georgetown University’s National 

Center for Cultural Competence for September 2020. Due to COVID-19, the in-person training was delayed and will 

now be held virtually through a series of webinars.

Key Activity: Develop Recommendations to 

Retain a Quality Direct Support Workforce 

• The Direct Support Professional Qualifications Workgroup, later renamed the bFair 2Direct Care Workgroup, brings 

together service providers, direct support workers, self-advocates, parent advocates, and representatives from the 

Idaho Department of Health and Welfare to develop a series of recommendations to increase the retention, skills, and 

knowledge of the direct support workforce. Discussion topics include required training and competencies of direct 

support workers, code of ethics, wages and benefits, career pathways, and direct support worker evaluations. The bFair 

2Direct Care workgroup successfully developed recommendations on a training competency and incentive program 

that aligns with best practice that will help create and keep quality direct support workers in Idaho.

• As with all products and recommendations produced by CNOW! workgroups, the Advocate Advisory Committee, a 

group of self-advocates and family members, reviewed the recommendations to ensure that the proposed process and 

systems changes clearly benefit those using HCBS.

Additional Activities:

• Convene Person-Centered Practice Workgroup: Supported by the Idaho Council on Developmental Disabilities 

and the Department of Health and Welfare, this workgroup works to develop person-centered practice facilitator 

qualifications, training models, and policy recommendations.

• Convene Self-Advocacy Training Workgroup: This workgroup promotes a train-the-trainer model to support 

individuals with individuals enhance their advocacy and leadership skills.
Living Well Annual Report Volume II: Grantee Profiles 17

VI. Analysis and Conclusion

A. Contextual Factors

The Idaho Living Well grant has been shaped by a number of external factors. The K.W. lawsuit, filed in 2012 with the 

intention of making Medicaid funding for individuals with I/DD more transparent, continues to be a factor. While 

implementing their project activities, the Idaho Living Well team has had to respond to and navigate the COVID-19 

pandemic, state budget cuts, the K.W. lawsuit, the cultural diversity of its population, and the needs of a variety of 

stakeholders. 

B. Model Design

The Idaho Living Well team puts at the forefront the voices and needs of people with disabilities in all of their project 

activities. The self-advocate led stakeholder group, CNOW!, utilized the active participation of family members, direct 

support professionals, providers, and state representatives to develop a number of trainings and topic-specific workgroups.

C. Key Activities

Born from CNOW!, the bFair 2Direct Care and the Quality Assurance Abuse and Neglect Reporting and Monitoring 

workgroups work to analyze and develop recommendations to improve community capacity building and community 

monitoring, respectively. The Self Advocacy Training Workgroup is driven by self-advocates who are designing the trainthe-trainer model and content of topical modules. Once implemented, individuals with I/DD will facilitate training 

statewide. 

The inclusion of the Advocate Advisory Committee to review and vet deliverables produced by the workgroups further 

ensures that the recommendations being produced by these workgroups directly benefit individuals with disabilities. 

The Idaho Living Well team is actively working with partners on improving the level of cultural competence within the 

state over the last several years. By providing cultural competency trainings to service providers, state agency personnel 

and the DD Network and adding Spanish interpretation during all meetings, the Idaho Living Well team has increased the 

level of cultural awareness and have created a more accessible and culturally competent environment for those with diverse 

backgrounds interacting within the system. Through their work with the CRAG and collaboration with the Georgetown 

National Center for Cultural Competence, the Idaho Living Well team continues to improves access to and quality of 

supports and services for the Idaho Latinx community.

As a whole, the Idaho Living Well team effectively collaborates with self-advocates and includes stakeholders across the 

state to develop trainings, courses, policy recommendations, and other resources that will continue on beyond the life of 

the grant.
Living Well Annual Report Volume II: Grantee Profiles 18

INDIANA

Living Well Grantee Profile

The Indiana Family and Social Services Administration Division of Disability and Rehabilitative Services (DDRS) received 

the five-year Living Well grant in 2018.

I. Grantee Information

The Indiana Family and Social Services Administration was established by the Indiana General Assembly in 1991 and is a 

health care and social services state agency with six care divisions. Within the Family and Social Services Administration, 

DDRS manages the delivery of services to children and adults with developmental disabilities (DD). 

Within DDRS, the Bureau of Quality Improvement Services monitors the quality of HCBS waiver services for individuals 

with DD and the organizations and providers who are approved to provide those services. They oversee the approval and 

enrollment of new providers, provider recertification, case record reviews, incident management, community monitoring 

and complaints. In addition, the Bureau of Quality Improvement Services assists in the distribution of multiple resources, 

quality-related trainings, and technical assistance. Further, the Bureau of Developmental Disabilities Services provides 

services for individuals with DD that enable them to live as independently as possible in their communities. As part of 

these efforts, the Bureau of Developmental Disabilities Services assists individuals in receiving community supports and 

residential services using a person-centered plan to help determine which services are needed and who can best provide 

them.

II. Grantee Partnerships

The DDRS partners with key stakeholders on their Living Well grant (collectively, the Indiana Living Well team) including, 

but not limited to, self-advocates, families, providers, the National Association of State Directors of Developmental 

Disabilities Services (NASDDDS) Culture of Quality, and Charting the LifeCourse (CtLC) Nexus Chapter through the 

University of Missouri Kansas City.
Living Well Annual Report Volume II: Grantee Profiles 19

III. State Context

Variations in access to quality home and community-based settings (HCBS) occur, in part, due to varying demographic, 

economic, political, and historical factors in each state. Key contextual factors are described here to better understand 

DDRS’s external conditions for their Living Well model. The COVID-19 pandemic rapidly evolved during the 2019-2020 

evaluation cycle with significant impact on the delivery of HCBS and the health and safety of individuals with intellectual 

and developmental disabilities (I/DD). The pandemic response influenced both how and the extent to which grantees 

implemented grant activities as planned and the local and state context in which the grant is being implemented.

Indiana DDRS oversees the Partners in Transformation stakeholder group, which maintains a common vision and set of 

goals to align systems change efforts; this includes engaging local and statewide stakeholders, defining quality metrics and 

service outcomes, providing education to system partners to help people achieve a “good life,” and supporting providers 

and case managers. Collectively, these activities work towards a system that supports the individual as the primary driver of 

their own life and the system as a whole using CtLC as an organizing framework. Systems change efforts in Indiana include 

the redesign of HCBS waivers administered by the Bureau of Developmental Disabilities Services and ongoing participation 

in the Supporting Families and Cultural Competency communities of practice. As a whole, DDRS is integrating their Living 

Well grant activities into broader systems change efforts. 

Indiana DDRS is the only state agency among the eight Living Well grantees. As a state agency, building trust can be 

difficult. The team is working to build a grassroots movement, but is sometimes constrained by DDRS’ competing priorities, 

such as their response to the COVID-19 pandemic. At the same time, DDRS’ role as a state agency can facilitate grant 

activities, such as alignment with other systems change initiatives.
Living Well Annual Report Volume II: Grantee Profiles 20

IV. Model and Objectives

The Indiana Living Well grant model focuses on using the CtLC organizing principles and framework. The Indiana 

Living Well team began by working to include self-advocates, families, direct support professionals (DSPs), and other 

key stakeholders. In concert with these stakeholders, the Indiana Living Well team is working to develop, and eventually 

implement, a new integrated proactive community monitoring system by examining the current system through the lens of 

the CtLC framework. The Indiana Living Well team and stakeholders are developing and disseminating toolkits using CtLC 

principles to support HCBS.

The Indiana Living Well team’s model objectives are:

1. Collaborate with and empower self-advocates, families, and key stakeholders throughout this project, ensuring full 

involvement in the development of practices, policies, and procedures to elevate HCBS;

2. Develop and implement an improved process for analyzing data from HCBS providers to influence practices, 

policies, and procedures for increasing quality of and access to services that improve positive outcomes for 

individuals with I/DD;

3. Develop and test toolkits for providers, individuals, and their families to improve monitoring of safety, health, and 

well-being of individuals with I/DD as well as reduce risk factors for abuse, neglect, and exploitation; and

4. Identify, develop, and implement an innovative approach to build the capacity of community supports for individuals 

with I/DD, bolstering paid and non-paid community services and supports.

V. Key Activities by Core Components

A. Community Monitoring

Community Monitoring includes efforts to develop a comprehensive system to monitor the health and well-being of 

individuals with I/DD living in a variety of home and community-based settings. The following are key activities reported 

by the Indiana Living Well team during this evaluation period to address this core component: 

Key Activity: Explore Data Collection Strategies and Systems

• The Indiana Living Well team continued addressing the challenge of community monitoring and reporting occurring 

in silos by examining what data are being collected and exploring potential data collection systems. The Indiana State 

Department of Health Division of Long Term Care, which oversees licensing and certification for long term care 

facilities, has a robust data collection system. The Indiana Living Well team will meet with representatives from the 

Division of Long Term Care to discuss strategies for data collection and integration. 

Key Activity: Identify Quality Indicators and Conduct Surveys 

• The Indiana Living Well team conducted an extensive review of literature, review of state policies, and interviews to 

identify quality indicators to inform a shift in culture and performance for DDRS and develop innovative strategies 

that impact Indiana’s systems change efforts. The Indiana Living Well team aligned strategies with the CtLC 

framework. Through this process, the team recognized a need to disseminate a survey to case managers, providers, 

and DSPs. The survey, developed in partnership with Indiana University, is for case managers, DSPs, and management 

of provider organizations. The goal of the survey is to gauge the priorities of respondents based on the direction they 

believe that the state agency has set.

• The Indiana Living Well team also began development of a survey to gather baseline data focused on expectations that 

individuals receiving supports and their families, providers, and other key stakeholders have for the state. The survey 

aims to capture what the perceived priorities of the state are compared to what the key stakeholders believe priorities 

should be.
Living Well Annual Report Volume II: Grantee Profiles 21

Key Activity: Revise Needs Assessment and Evaluation Plan 

• The Indiana Living Well team continued to revise the ongoing needs assessment and evaluation plan based on the 

project’s activities and focus. Part of these efforts included analysis of Indiana’s National Core Indicators (NCI) from 

2015-2018. Staff shared results from the analysis at the NCI Annual Meeting.

• The Indiana Living Well team discussed efforts to link NCI data, portal data, and Medicaid reimbursement data to gain 

a stronger understanding of what data gaps exist. The team also began discussions on what questions to add to the NCI 

survey to support understanding of three CtLC domains and waiver redesign. In order to avoid redundancy, Indiana 

Living Well team members planned to review three existing data sources first.

B. Community Capacity Building

Community Capacity Building includes efforts to increase the skills and knowledge of all individuals, families, and service 

providers in the HCBS system. The following are key activities reported by the Indiana Living Well team during this 

evaluation to address this core component: 

Key Activity: Align Efforts Across Systems

• The Indiana Living Well team engaged key stakeholders in the state with partners in NASDDDS Culture of Quality 

and the CtLC Nexus through University of Missouri-Kansas City to inform a collective impact approach to align state 

initiatives with broader systems change efforts. For example, the Indiana Living Well team initiated efforts to align 

their work in the Community of Practice for Cultural and Linguistic Competency in Developmental Disabilities with 

the CtLC framework and the Living Well grant work to ensure adequate consideration of people’s backgrounds and 

cultures. The team shared this goal with stakeholders at a meeting in January 2020. Additionally, the Indiana Living 

Well team used Culture of Quality resources to develop a weekly residential provider check-in process via phone call, 

in response to COVID-19. This process enabled the Indiana Living Well team to support providers with key challenges 

in a timely, collaborative manner. Based on the results and feedback from this process, the team is exploring how to 

leverage this approach into its broader community monitoring approach. As a result, staff recorded detailed steps of 

the process and progress, including how they trained staff and analyzed data, to inform future Living Well and other 

related efforts.

Key Activity: Conduct a Series of Trainings and 

Events for Self-Advocates, Families, and Providers 

• The Indiana Living Well team worked to ensure self-advocates and families have equal footing with other stakeholders. 

The CtLC Ambassador Series included self-advocates, and the team reserved several other Ambassador Series’ targeted 

at different stakeholder groups (e.g., self-advocates, families, providers, and case managers) to build leadership and 

encourage participation.

• A subset of the larger grant team was developed to serve as the leadership group. The group includes self-advocates, 

families, providers, and other system stakeholders, including the Governor’s Council and Protection & Advocacy 

representatives, who are also self-advocates. The leadership group participated in a policy-focused Ambassador Series 

to support team development and improve information-sharing.

• The Indiana Living Well team began development of a series of provider trainings on the CtLC framework, as well as 

partnerships to provide on-the-ground support to self-advocates. The provider trainings aim to ensure that providers 

can facilitate self-advocate leadership opportunities in the future.
Living Well Annual Report Volume II: Grantee Profiles 22

VI. Analysis and Conclusion

A. Contextual Factors

The Indiana Living Well team is uniquely positioned within a state agency, and leverages this role by capitalizing on 

existing partnerships, access to key stakeholders, and rapport built across systems since the agency’s inception. As a 

result, the Indiana Living Well team works closely with leadership across partner agencies to integrate Living Well goals, 

philosophies, and activities for short- and long-term support. While there is some apprehension among individuals about 

DDRS’ ability to impact true systems change as an agency tied to fluctuating priorities, such as COVID-19, the Indiana 

Living Well team built strong partnerships with other agencies early on, allowing the team to disseminate Living Well 

project information widely and generate enthusiasm around the project across systems. The Indiana Living Well team also 

has a unique opportunity to engage with other related grants in which DDRS is involved, such as an advocacy grant with 

the Arc of Indiana, and braid Living Well goals to those existing opportunities.

B. Model Design

The Indiana Living Well team utilizes a variety of strategies to build on existing structures in the state while updating or 

creating new tools to promote Living Well activities. Notably, the state focuses on how to embed the CtLC framework in a 

range of initiatives, which supports alignment across their work. Through integration of the framework, the Indiana Living 

Well team strengthened stakeholder engagement and improved person-centered thinking among agency leadership. In 

tandem, key partnerships, such as with NASDDDS, support transformational change in the way HCBS are implemented 

in the state. Indiana’s Living Well objectives include areas of focus across a wide range of stakeholders, from self-advocates 

and families to policymakers, in order to affect change on a systems-level and offer effective, scalable, and sustainable 

products that will continue even after the grant ends.

C. Key Activities

The Indiana Living Well team works to create opportunities for self-advocates and family members to serve in leadership 

roles and trains providers to create similar opportunities, which also serves as a strategy to uphold Living Well philosophies 

once the grant ends. In order to sustain and scale data collection and evaluation tools, the Indiana Living Well team 

developed metrics to assess progress. These include creating surveys and working with quality managers to review data 

collection methods and use, update provider reviews and examine provider-level outcomes, and build provider capacity 

based on incident reporting. All of these activities provide critical information on gaps that may exist and other areas 

of need to better inform and drive the conversation on the trajectory of the Living Well project, including as it relates to 

sustainability. Overall, the Indiana Living Well team capitalizes on existing systems change momentum to integrate Living 

Well goals and achieve desired outcomes through hands-on activities with self-advocates, families, community members, 

providers, care coordinators, and other state agencies.
Living Well Annual Report Volume II: Grantee Profiles 23

MISSOURI

Living Well Grantee Profile

The University of Missouri, Kansas City Institute for Human Development (UMKC-IHD) received the five-year Living Well 

grant in 2018.

I. Grantee Information

The UMKC-IHD is a University Center for Excellence in Developmental Disabilities Education, Research, and Service 

established in 1977 that works to promote self-determination among people with disabilities. The organization has an 

Advisory Leadership Team, comprised of adults with disabilities, family members, and leaders from the Missouri Division 

of Developmental Disabilities, Missouri Developmental Disabilities (DD) Council, Missouri Protection and Advocacy, 

Missouri Assistive Technology, Senate Bill 40 Boards, and other stakeholders that provides feedback on priorities and 

activities and participates in education efforts and coalition building.

The UMKC-IHD focuses on research and evaluation, program development, and training and technical assistance; they 

participate in and lead projects to promote the inclusion and well-being of individuals with disabilities in Missouri. These 

include the iPad and iPhone Application for Prevention of Sexual Abuse, which involves the development of an app for 

people with disabilities to use for trainings and education; the People First of Missouri Technical Assistance project, an 

initiative to assist members of the state’s People First coalition through ad hoc technical assistance; and the Kansas City 

Hispanic Needs Assessment, a project developed to assess current conditions, assets, and needs of the Latinx population 

in the Greater Kansas City area. The UMKC-IHD also houses the LifeCourse Nexus, a community of learning that brings 

people together to work towards transformational change within organizations, systems, and communities to support 

“good lives for all people.” The LifeCourse Nexus both utilizes and continually refines the Charting the LifeCourse (CtLC) 

framework and tools to create a common language and philosophy for shaping and supporting innovation in policy, 

practice, procedure, and culture.
Living Well Annual Report Volume II: Grantee Profiles 24

II. Grantee Partnerships

The UMKC-IHD partners with key stakeholders on their Living Well grant (collectively, the Missouri Living Well 

team) including, but not limited to, Missouri Department of Mental Health Division of Developmental Disabilities (the 

Division), People First Missouri, the Missouri DD Council, Missouri Protection & Advocacy, the Missouri Association of 

County DD Services, the Marf (the Provider Association), and the Missouri Family-to-Family Resource Center. National 

partners include the Human Services Research Institute and the National Association of State Directors of Developmental 

Disabilities Services.

III. State Context

Variations in access to quality home and community-based services (HCBS) occur, in part, due to varying demographic, 

economic, political, and historical factors in each state. Key contextual factors are described here to better understand 

UMKC-IHD’s external conditions for their Living Well model. The COVID-19 pandemic rapidly evolved during the 

2019-2020 evaluation cycle with significant impact on the delivery of HCBS and the health and safety of individuals with 

intellectual and developmental disabilities (I/DD). The pandemic response influenced both how and the extent to which 

grantees implemented grant activities as planned and the local and state context in which the grant is being implemented. 

The UMKC-IHD continues to frequently convene stakeholders in Missouri, resulting in a strong collaboration across 

partners. The organization is engaged in disability-focused conversations and initiatives across the state. For example, 

UMKC-IHD conducts National Core Indicators (NCI) data collection. As a result, there is a longstanding partnership 

and consistent communications that facilitates awareness about what may be beneficial in the state, how to identify needs 

through Living Well grant work, and how to best align grant goals with other state initiatives. Additionally, the DD Council 

partnered with the Missouri Living Well team as part of their needs assessment for their next five-year plan. 

The Division partners with UMKC-IHD through an annual contract, designed to support the division in its implementation 

of system wide enhancements to better support people with I/DD throughout the state. One result of this partnership 

are various capacity building curricula for multiple target audiences (including self-advocates, support coordinators, 

and community health workers). The Division also plans to implement the Health Risk Screening Tool, a web-based tool 

designed to screen for health risks among vulnerable populations, particularly people with disabilities. The Missouri Living 

Well team, in collaboration with the Division’s leaders team is assessing what role the Living Well grant may play in the roll 

out and scaling of the identified and planned community monitoring and capacity building enhancement strategies of the 

Division. This may include using Living Well pilot sites, conducting evaluations, assisting with phased implementation, and 

making Missouri-specific modifications to the identified tools.
Living Well Annual Report Volume II: Grantee Profiles 25

IV. Model and Objectives

The Missouri Living Well team is leading a diverse group of stakeholders to measure performance, develop a data 

visualization system, and build capacity through implementation of new tools and trainings. The team developed a levels 

of impact framework to organize their efforts and ensure that they are addressing the goals of their Living Well model at 

all levels of the DD system. The levels include self-advocate networks, family networks, support coordination entities, DD 

service provider organizations, the DD system, and cross-system organizations. The Missouri Living Well team is building 

on previous technical assistance experience and the CtLC framework, of which they were a lead developer. Their grant 

model contains both statewide activities and local engagement through county collaborative teams. These teams represent 

six of the state’s 114 counties in the initial development phase, with plans to expand the county collaboratives to additional 

counties in future grant years.

The Missouri Living Well team’s model objectives are:

1. To engage diverse partners in the design, implementation, and replication of the model;

2. Develop and implement a coordinated system for monitoring safety, health, and well-being of individuals with DD 

living in a variety of community settings; and,

3. To design, identify, and implement a range of evidence based practices and innovative strategies including training 

for direct service professionals and HCBS providers, designed to improve services in the community.

V. Key Activities by Core Components

A. Community Monitoring

Community Monitoring includes efforts to develop a comprehensive system to monitor the health and well-being of 

individuals with I/DD living in a variety of home and community-based settings. The following are key activities reported 

by the Missouri Living Well team during this evaluation period to address this core component: 

Key Activity: Develop Virtual Data 

• The Missouri Living Well team partnered with Human Services Research Institute to build a data dashboard to 

improve the accessibility and usefulness of data. The team engaged in a mapping exercise to identify data currently 

available to the team and data collected by project stakeholders. Through the CtLC Ambassador Series for Systems 

Transformation, county collaborative members recommended quality of life indicators for the dashboard and 

identified strengths and areas of improvement related to data collection and availability. This exercise identified 

data that are currently available and gaps that exist. The dashboard, which is still under development, currently 

includes NCI, Centers for Disease Control and Prevention, and census data. The dashboard will provide background 

information and case studies before displaying the actual data to provide context for users. The team is still collecting 

feedback on the dashboard an identifying additional data sources, such as critical incident data from the division.
Living Well Annual Report Volume II: Grantee Profiles 26

B. Community Capacity Building

Community Capacity Building includes efforts to increase the skills and knowledge of all individuals, families, and service 

providers in the HCBS system. The following are key activities reported by the Missouri Living Well team during this 

evaluation period to address this core component: 

Key Activity: Conduct CtLC 

Ambassador Series for System 

Transformation with County 

Collaborative Groups 

• The Missouri Living Well team engaged and coached approximately 90 participants across six counties included in the 

pilot, including representatives from various levels of the DD system in each county, such as people who use services, 

providers, and county boards. Participants are using the CtLC Ambassador Series for Systems Transformation to 

discuss and identify their strengths and areas for growth in their role, their organization, and their community.

• County collaborative teams will develop and implement a strategic action plan to enhance capacity building or 

community monitoring in their local county, based on priorities identified throughout the series. 

• The county collaborative teams piloted the Missouri Living Well team’s new toolkit for system transformation. The 

toolkit is based on the CtLC framework and includes brainstorming and strategic planning resources. As the first pilot 

cohort wrapped up the series, the team evaluated the toolkit and process to identify areas for improvement. The team 

will make any changes to the series and is recruiting a new group of county collaborative teams to begin a second pilot 

group.

Key Activity: Establish Innovation Collaboratives

• The Missouri Living Well team established five innovation collaboratives to address specific topics of interest, such 

as data informed decision-making and person-centered support coordination. Each workgroup is currently led by 

members of the Missouri Living Well team and open to members of county collaborative groups from the first pilot 

cohort. Early workgroup members will form a steering committee for each workgroup and the Missouri Living Well 

team will expand the workgroups to the next cohort of county collaborative members once they complete training and 

coaching in CtLC (i.e., the Ambassador Series for Systems Transformation). The workgroups were launched in April 

2020 and are in the early stage of development.

• The Missouri Living Well team is developing evaluation plans for each of the innovation workgroups. The evaluation 

plans will evaluate the goals, objectives, and activities of each workgroup in relation to the overall project outcomes.

Additional Activities:

• Conduct Training Using CtLC in Your Own Life Curriculum: The Missouri Living Well team is conducting trainings 

for self-advocates through their ‘Using CtLC in Your Own Life’ to build self-advocate capacity.

• Conduct CtLC Family Leadership Ambassador Series: The Missouri Living Well team is also conducting capacity 

building training for family members of individuals with I/DD.

• Partner with Station MD: The Missouri Living Well team worked with the Division to bring Station MD to all 

recipients of the Division’s Medicaid HCBS waivers. Station MD provides 24/7 access to an on-call emergency room 

physician who specializes in treating individuals with I/DD. The implementation of Station MD was accelerated by 

the COVID-19 pandemic. In HCBS settings, DSPs can consult with a physician prior to visiting the hospital, which 

reduces unnecessary emergency room visits. If medical care is required, Station MD physicians can consult with 

the individual’s providers to ensure quality care. Missouri Family-to-Family has supported the effort by using their 

platform to share information and tips about using Station MD.
Living Well Annual Report Volume II: Grantee Profiles 27

VI. Analysis and Conclusion

A. Contextual Factors

The Missouri Living Well team is leveraging their levels of impact model and the CtLC framework to implement grant 

activities. The team is both strengthening existing partnerships and creating new partnerships to support their work. The 

Missouri Living Well team reports that their relationship with the Division is a significant advantage and is allowing them 

to integrate grant goals with the Division’s strategic initiatives and the DD Councils next five-year state plan. 

B. Model Design

Missouri’s Living Well model addresses grant objectives both locally and statewide. The levels of impact framework helps 

the Missouri Living Well team ensure that all levels of the DD system are targeted for improvement. The development, 

pilot, and evaluation of the new CtLC Ambassador Series for Systems Transformation is both driving positive changes in 

the communities participating in the pilot process and developing tools for future use. 

C. Key Activities

The Missouri Living Well team is developing new tools, implementing existing tools, and developing new and fostering 

existing partnerships through their Living Well grant. The Missouri Living Well team’s multifaceted approach will lead to 

new tools and outputs that are sustainable beyond the grant funding period. Changes being identified and implemented 

at the county level will spur systems change in the coming years and the data dashboard will inform future decisions. The 

Missouri Living Well team intends to continue developing and implementing these tools, making modifications based on 

their internal evaluations and engaging new county collaborative teams in the final years of the grant. These finalized tools 

will then be ready for sustained use by other stakeholders in Missouri, as well as across the country.
Living Well Annual Report Volume II: Grantee Profiles 28

NEW HAMPSHIRE

Living Well Grantee Profile

The University of New Hampshire Institute on Disability (UNH IOD) received the five-year Living Well grant in 2017.

I. Grantee Information

The UNH IOD was established in 1987 and is the state’s University Center for Excellence in Developmental Disabilities 

Education, Research, and Service. The UNH IOD builds local, state, and national capacity to serve the needs of people with 

disabilities and their families through research, academic, service, and dissemination initiatives. These initiatives focus on 

various areas, including assistive technology, community living and employment, inclusive early care and education, and 

health and genetics.

New Hampshire’s IOD is involved in related projects that address disability topics across the lifespan. These include the 

New Hampshire Disability and Public Health Project, which aims to improve the health and quality of life of people 

with disabilities in the state; Inclusive Communities, a project focused on promoting acceptance and inclusion of people 

with disabilities in schools and communities through documentary film; and Disability Statistics and Demographics 

Rehabilitation Research and Training Center, a center that works to alleviate gaps between producers and end users of 

disability statistics in order to support better data collection, more effective programs, and better lives for people with 

disabilities.

II. Grantee Partnerships

The UNH IOD partners with key stakeholders on their Living Well grant (collectively, the New Hampshire Living Well 

team) including, but not limited to, the Council on Developmental Disabilities, the New Hampshire Department of Health 

and Human Services Bureau of Developmental Services, Easter Seals New Hampshire, and the Disability Rights Center.
Living Well Annual Report Volume II: Grantee Profiles 29

III. State Context

Variations in access to quality home and community-based services (HCBS) occur, in part, due to varying demographic, 

economic, political, and historical factors in each state. Key contextual factors are described here to better understand 

IOD’s external conditions for their Living Well model. The COVID-19 pandemic rapidly evolved during the 2019-2020 

evaluation cycle with significant impact on the delivery of HCBS and the health and safety of individuals with intellectual 

and developmental disabilities (I/DD). The pandemic response influenced both how and the extent to which grantees 

implemented grant activities as planned and the local and state context in which the grant is being implemented. 

In January 2020, New Hampshire’s Department of Health and Human Services (DHHS) confirmed a new commissioner. 

The New Hampshire Living Well team met with the new UNH IOD director and the DHHS Director of Long-Term 

Services and Supports to ensure that the Living Well grant continues to support the quality efforts of DHHS as well as the 

new commissioner. 

New Hampshire DHHS is implementing a corrective action plan based on the HCBS settings rule for conflict-free case 

management, which is now called conflict-free service provision. The Living Well grant has supported the state’s efforts to 

implement measures necessary to meet the conflict free requirement, as well as meeting compliance with the final settings 

rule. As a result, the New Hampshire Living Well team, with input from stakeholders, identified additional changes that 

need to be made to the state’s Service Agreement template which is on the Health Risk Screening (HRS) platform. Revisions 

to the Service Agreement and supporting documentation will include documentation of HCBS expectations and allow for 

ongoing monitoring of the settings requirements. Alterations to the use of the HRS platform will support the state’s efforts 

towards conflict-free service provision by including access to multiple providers for each individual’s record. 
Living Well Annual Report Volume II: Grantee Profiles 30

IV. Model and Objectives

The New Hampshire Developmental Services Quality Council provides leadership for the consistent review and 

improvement of the quality of DD within the system. The Quality Council acts as an advisory group to the New Hampshire 

Living Well project, titled the New Hampshire Quality Framework. 

The objectives of the New Hampshire Quality Framework are as follows: 

1. Self-advocates, family members, DD network members, and other stakeholders will actively engage in the full 

implementation of the project.

2. The New Hampshire Quality Framework will demonstrate a comprehensive system to improve services for 

individuals living in the community.

3. Direct support professionals (DSPs) and other HCBS providers will demonstrate improved competencies to improve 

access to and quality of HCBS services to individuals in the community.

4. The community monitoring system in New Hampshire will demonstrate an increase in tools, training and other 

strategies to address all types of abuse, neglect, and exploitation.

5. DSPs and other HCBS providers will demonstrate increased understanding and follow through on health issues and 

the supports needed.

6. The project evaluation process will measure and report on activity progress, barriers, and areas of improvement.

7. The New Hampshire Quality Framework will demonstrate a sustainability plan that reflects organizational, financial, 

and community sustainability.

The New Hampshire Living Well team is supporting the way that providers across the state collect and analyze data. The team 

strategically leverages their strong, long-lasting partnerships across the state to implement evidence based practices to improve 

the health and safety of individuals with disabilities. The New Hampshire Living Well team encourages collaboration within 

the state, and their involvement of other partners in the development of trainings and key activities have resulted in vetted and 

effective resources.

V. Key Activities by Core Components

A. Community Monitoring

Community Monitoring includes efforts to develop a comprehensive system to monitor the health and well-being of 

individuals with I/DD living in a variety of home and community-based settings. The following are key activities reported 

by the New Hampshire Living Well team during this evaluation period with the main goal of addressing this core 

component: 

Key Activity: Expand and Refine Data Collection using the HRS Platform 

• As part of the effort to continue to improve the community monitoring system in New Hampshire and move from 

paper-based to electronic data collection and documentation methods, the New Hampshire Living Well team 

partnered with Health Risk Screening, Inc. to expand the system based on a comprehensive review and crosswalk of 

data collection requirements. Through this partnership, the team identified changes needed for the HRS platform, 

which hosts the Health Risk Screening Tool (HRST), the New Hampshire Service Agreement, the Supports Intensity 

Scale, the Planning Process Acknowledge Form, the Service Agreement Amendment Form, and the Quarterly 

Satisfaction Surveys. The regulations in New Hampshire require there to be quarterly satisfaction check-ins with 

individuals with disabilities, family members, and guardians. These surveys were originally paper-based, but will be 

hosted on the HRS platform.

• The New Hampshire Living Well team updated the service agreement used by providers in the region to collect data 

on regulatory requirements, waiver sub-assurances, file review audits, and home and community-based services 

compliance. To achieve this, the New Hampshire Living Well team obtained feedback from service coordinator 
Living Well Annual Report Volume II: Grantee Profiles 31

supervisors, certification and licensing, New Hampshire Living Well team, and the Bureau of Developmental Services 

to ensure each stakeholder’s needs are addressed. The HRS platform is used statewide for the Person-Centered 

Planning documentation and HRST. The additional information/forms that will be captured in the HRS platform will 

support regional and statewide quality monitoring efforts.

• The HRST is used to detect health risks and destabilization early. The HRST assigns scores to 22 health and 

behavioral-related rating items. The total points result in a Health Care Level (HCL) with an associated degree of 

health risk. HCLs can range from 1 through 6; Level 1 being the lowest risk for health concerns and Level 6 being 

the highest risk for health care concerns. The HRST diagnoses are auto-populated into the service agreement to 

avoid duplication of effort for service coordinators and to eliminate errors. This is especially helpful when filling 

out information for those with dual diagnoses. The HRST also has a referral section that includes assessments of 

risk, communication, behavioral health, and assistive technology. The HRS helps to ensure that health conditions 

are not overlooked by an individual’s team by capturing health related data on a regular basis. The Living Well grant 

is supporting the state’s enhancement of the managed care organizations (MCOs) role by notifying them when an 

individual’s Health Care Level is 3 or above. The MCO will then take advanced measures to work with the individual 

and their team to address health care issues, ultimately preventing the Health Care Level from increasing. 

B. Community Capacity Building

Community Capacity Building includes efforts to increase the skills and knowledge of all individuals, families, and service 

providers in the HCBS system. The following are key activities reported by the New Hampshire Living Well team during 

this evaluation period with the main goal of addressing this core component:

Key Activity: Accelerate and Conduct 

Medication Administration Training 

• In New Hampshire, the original medication administration training for direct support professionals was eight hours 

long, only available in English, and had not been updated in twelve years. It was recognized that the lack of updated 

information and inconsistency in presentation (use of the DVD) impacted DSP success. As the New Hampshire team 

recognized that a large portion of the staff administering medication did not speak English as their first language, 

the New Hampshire Living Well team updated and translated the training to the three top languages spoken by staff, 

Spanish, Dzongkha, and Nepalese.

• In support of DHHS during the pandemic, the New Hampshire Living Well team was able to provide DHHS with the 

almost completed (missing the video demonstration components) medication administration training to put onto the 

Relias online training platform. This allowed for ongoing medication administration to occur during the pandemic 

when it was not possible to hold in-person trainings. The training allowed for medication administration to continue 

and for staff and home providers to receive initial or re-authorization training during the epidemic.

• The videos that will be included in the training will cover various aspects of medication administration. Topics 

covered by the videos include how to interact with individuals that do not wish to take their medication, as well 

as demonstrations of how to administer certain medications. Furthermore, the training had embedded evaluation 

questions throughout the training to measure the impact of the training on medication administration practices. If 

this training continues to be successful, it will result in the reduction of staff that lose their medication administration 

privileges and will improve the longevity of DSPs and home providers. 
Living Well Annual Report Volume II: Grantee Profiles 32

VI. Analysis and Conclusion

A. Contextual Factors

The New Hampshire Living Well team utilizes their strong and long-lasting partnerships with self-advocates, direct 

support professionals, state agencies, providers, families, and advocacy organizations to improve the supports and services 

for people with disabilities within the state. As New Hampshire is a small state, they are able to work collaboratively 

with stakeholders and maintain strong buy-in for their initiatives. Additionally, New Hampshire responded to issues of 

cultural diversity that sometimes impact how DSPs deliver supports and participate in the workforce. In response, the 

New Hampshire Living Well team actively considers cultural and linguistic diversity across activities to enhance DSP 

employment, retention, and delivery of supports to ensure optimal performance in the service delivery system.

B. Model Design

The New Hampshire Living Well team actively engages stakeholders and individuals with disabilities in the development 

and implementation of all project activities. Through the Quality Framework, the team addresses numerous barriers in 

data collection system to improve community monitoring efforts within the state. By regularly surveying and coordinating 

with direct support professionals, the New Hampshire Living Well team is able to build capacity through the development 

of resources that build the competencies of DSPs.

C. Key Activities

The reliance on paper-based data collection and the lack of a standardized reporting and monitoring system within the 

state led the New Hampshire Living Well team to adopt the HRS platform to support data collection. By moving to an 

electronic-based platform, the team is improving data collection and streamlining crucial elements of the community 

monitoring system for all stakeholders. The New Hampshire Living Well team’s inclusion of stakeholders throughout 

the development of the platform both strengthens existing partnerships and ensures the final product is relevant, 

appropriate, and best serves the needs of the community. Having one platform used across the system will result in more 

comprehensive, up-to-date data collection that can be easily accessed to run reports and identify trends.

The medication administration training was born out of the New Hampshire Living Well team’s realization that the 

DSPs most likely to lose their medication administration privileges are those whose primary language is not English. 

Additionally, the state was interested in updating the way in which the training was offered due to the age of the video 

and its’ content. The action taken to update the medication administration training to make it more accessible will help 

improve the retention of the staff in the workforce and make entering the workforce easier for new employees. Hosting the 

medication administration training online ensures accessibility of the resource beyond the lifespan of the grant, in addition 

to the components of the live, in-person training being distributed throughout the state. 
Living Well Annual Report Volume II: Grantee Profiles 33

VIRGINIA

Living Well Grantee Profile

The Virginia Commonwealth University (VCU) Partnership for People with Disabilities (the Partnership) received the fiveyear Living Well grant in 2017.

I. Grantee Information

The Partnership, Virginia’s University Center for Excellence in Developmental Disabilities Education, Research, and 

Service, works to promote inclusion of people with disabilities within their communities. The Partnership was founded 

in 1985 and has three main focus areas that encompass the work they do: early childhood education for families and 

educators, early childhood supports and services, and supports based on self-determination and inclusion for adults with 

disabilities. Further, their programs cover community living, early childhood and early intervention, education, and health. 

The Partnership’s projects include the Leadership for Empowerment and Abuse Prevention project, which provides training 

by and for people with disabilities about prevention of abuse by establishing healthy relationships; Cost and Outcomes 

for People with Intellectual and Developmental Disabilities (I/DD) Who Use Services in Virginia, a project that involves 

research on the relationship between cost and outcomes for people with I/DD who use home and community-based 

services (HCBS) in Virginia; and the Regional Educational Assessment Crisis Response and Habilitation Evaluation, for 

which the organization designs and implements a program evaluation of the state’s regionally-based crisis system. 

II. Grantee Partnerships

The Partnership partners with key stakeholders on their Living Well grant (collectively, the Virginia Living Well team) 

including, but not limited to state Department of Medical Assistance Services, Department of Behavioral Health & 

Developmental Services, Virginia Board for People with Disabilities, disAbility Law Center of Virginia, Arc of Virginia, 

Richmond Resources for Independent Living, Center on Transition Innovations, and community-based provider 

organizations in the Richmond and Virginia Beach areas.
Living Well Annual Report Volume II: Grantee Profiles 34

III. State Context

Variations in access to quality HCBS occur, in part, due to varying demographic, economic, political, and historical factors 

in each state. Key contextual factors are described here to better understand the Partnership’s external conditions for their 

Living Well model. The COVID-19 pandemic rapidly evolved during the 2019-2020 evaluation cycle with significant 

impact on the delivery of HCBS and the health and safety of individuals with I/DD. The pandemic response influenced 

both how and the extent to which grantees implemented grant activities as planned and the local and state context in which 

the grant is being implemented.

Virginia experienced a number of leadership changes at the state level and among provider agencies. An acting 

commissioner for Developmental Services is in place at the Department of Behavioral Health & Developmental Services 

until a new commissioner is appointed. The Virginia Living Well team has an existing relationship with the acting 

commissioner. Under the acting commissioner, the agency’s current focus is bringing the U.S. Department of Justice 

(DOJ) settlement agreement with the Department of Medical Assistance Services and the Department of Behavioral 

Health & Developmental Services to a close. As of now, the state has settled on 250 indicators and recently distributed a 

list of requirements that community service boards and providers must meet. Providers that do not meet the requirements 

will incur a penalty while being required to maintain current service levels. The service system does not want to sign an 

agreement that is open-ended, so the Department of Medical Assistance Services and the Department of Behavioral Health 

& Developmental Services and DOJ have reached a stalemate. This, coupled with state priority shifts due to COVID-19, 

stalled further coordination between the Virginia Living Well team and the commissioner on Living Well activities. 

While these leadership changes have not directly impacted capacity building efforts with HCBS providers, they impact 

the Virginia Living Well team’s ability to enact systems-level changes. The Virginia Living Well team is focused on 

understanding how to maintain project momentum despite these changes. In addition to their collaboration with the 

Virginia Disability Determination Services, the Virginia Living Well team is developing relationships with the state 

Medicaid agency, particularly Medicaid staff who handle DD policy work. Members from the Medicaid agency regularly 

attend leadership meetings, and the collaboration will allow for continuity and the development of new project activities 

while the Virginia Disability Determination Services is in transition.
Living Well Annual Report Volume II: Grantee Profiles 35

IV. Model and Objectives

The Virginia Living Well grant model utilizes leadership from Regional Quality Councils, established by the DOJ 

settlement, to work closely with partners and the Virginia Living Well team. The team, the Regional Quality Councils, and 

their partners are developing and implementing interventions in diverse regions throughout the state. The evidence based 

interventions will include training for individuals with I/DD and their supporters and will be supported by a multi-tiered 

monitoring system. 

The Virginia Living Well team’s model objectives are:

1. A replicable and sustainable model process for system change implementation is in place for collaboration among 

diverse stakeholders, to manage systems capacity building, and to monitor individual, regional, and systems’ 

outcomes and impact;

2. A coordinated model of evidence based and informed interventions managed through the Regional Leadership 

Team comprised of diverse stakeholders will a) expand knowledge and skills of people with I/DD and those who 

support them; b) generate innovative and responsive policy that encourages independence and full engagement in 

community life; and c) produce process data and outcomes that will serve as a national model for integrated, effective 

I/DD supports and services; and, 

3. A multiagency, multi-tiered system of HCBS and community monitoring managed through a diverse leadership team 

will coordinate and augment disparate monitoring and quality initiatives in Virginia to serve as a national model 

for a) improving and increasing identification of health and safety risks for people with I/DD who use, and those 

waiting for, HCBS services; b) using varied data points gathered from multiple organizational and agency partners to 

develop high quality data rich analysis and reporting; and c) documenting process and outcome data that facilitate 

continuous quality improvement in community programs.

V. Key Activities by Core Components

A. Community Monitoring

Community Monitoring includes efforts to develop a comprehensive system to monitor the health and well-being of 

individuals with I/DD living in a variety of home and community-based settings. The following are key activities reported 

by the Virginia Living Well team during this evaluation period to address this core component: 

Key Activity: Initiate COVID-19 Tracking within Provider Agencies 

• Since the start of the coronavirus pandemic, disAbility Law Center Virginia has reviewed and logged every 

Computerized Human Rights Information System report that mentions COVID-19. This includes any time an 

individual is tested or treated for COVID-19, or cases when individuals were unable to access testing or other 

necessary services related to COVID-19 precautions. The onus then is on the service providers within the region to 

help individuals access treatment and testing. The disAbility Law Center Virginia distributed surveys to evaluate how 

easily providers and individuals have been able to access testing, ensuring to document the barriers reported and 

noting the issues providers state experiencing while trying to obtain personal protective equipment. Specific incidents 

tracked included the number of COVID-19 cases in congregate settings for people with I/DD, access to health and 

mental health services, peer on peer abuse, and overall congregate care quarantine responses. 

Key Activity: Utilize Medicaid Claims, Supports Intensity Scale 

(SIS), and National Core Indicators (NCI) Data Analysis 

• The Virginia Living Well team used the existing data analysis of Medicaid claims data, SIS, and the NCI data for 

individuals with I/DD in the community to understand the best predictors and outcomes for people with disabilities. 

From this analysis, the Virginia Living Well team found that individuals with I/DD who are employed have better 

access to rights, choice, and community participation than those who do not work. 
Living Well Annual Report Volume II: Grantee Profiles 36

• Findings demonstrated that those with dual diagnoses had better outcomes than those that do not have dual 

diagnoses. This is potentially due to these individuals being connected to a greater number of services and supports. 

The Virginia Living Well team is using the findings from this study to inform their approach to employment 

opportunities for individuals with I/DD and their grant activities as a whole.

B. Community Capacity Building

Community Capacity Building includes efforts to increase the skills and knowledge of all individuals, families, and service 

providers in the HCBS system. The following are key activities reported by the Virginia Living Well team during this 

evaluation period to address this core component:

Key Activity: Develop and Implement Regional Quality Council Trainings 

• As part of the Virginia settlement agreement, the DOJ requires Regional Quality Councils in Virginia to receive 

formal quality improvement and assurance training. To meet the DOJ training requirements, the Virginia Living 

Well team worked with the technical assistance provider for the Living Well grant, Mission Analytics, and their 

subcontractor, Human Services Research Institute, to develop a webinar series for the Regional Quality Councils 

around quality improvement. Through this collaboration, the Virginia Living Well team was able to identify presenters 

and develop content material for the series. Three of the webinars in the series will be presented live on the following 

topics;

• Introduction to Quality Improvement

• Quality Improvement Tools and Facilitation

• Making the Most of Quality Improvement Data

• In addition to the three live webinars, there are five pre-recorded modules on the following topics:

• The History, Purpose, and Membership of Regional Quality Councils

• Operating Highly Effective Teams

• Supporting People with Disabilities and Family Members as Essential Partners in Quality Improvement

• Identifying, Understanding, and Prioritizing DD Data

• Moving from Discussion to Action: Quality Improvement Planning and Helpful Quality Improvement Tools.

Key Activity: Conduct Leadership for Empowerment 

and Abuse Prevention (LEAP) Trainings 

• The Virginia Living Well team, in partnership with the LEAP Project, is providing trainings to adults with I/DD on 

healthy relationships and information on how to prevent abuse to adults with disabilities. 

• Adults with I/DD who participated in LEAP training completed pre- and post-test measures. Participants watched and 

responded to video vignettes before and after the training intervention to identify the difference between healthy and 

unhealthy relationships.

Key Activity: Plan and Conduct Person Centered Thinking Training 

• The Virginia Living Well team, in collaboration with The Learning Community for Person Centered Practices, plans 

to offer Person Centered Thinking training in the fall. To increase training attendance, demand, and interest, capacity 

building training opportunities are being announced earlier in the year to community based organizations and 

potential attendees.

• Person Centered Thinking trainer support calls are held quarterly, and mentors attend monthly calls with the Learning 

Community. Person Centered Thinking mentors are working with the Learning Community to identify virtual 

training formats that can be replicated in Virginia. 
Living Well Annual Report Volume II: Grantee Profiles 37

Additional Activities:

• Implement the Discovering ME! Program: Discovering ME! is an age-appropriate program that promotes career 

discovery for younger individuals with disabilities still in school.

• Transition Positive Behavioral Support (PBS) Trainings to Virtual Format: The Positive Behavior Support Trainings, 

aimed at increasing an individual’s competence in community-based settings through the application of behavioral 

techniques, were intended to be held in-person but have been transformed to a virtual format. 

• Conduct Communication and Health Advocacy Trainings (CHAT): VCU provides health literacy trainings to adults 

with disabilities and the individuals that support them. 

• Provide Support to Families: The Family to Family (F2F) Network provides one-on-one emotional and informational 

support for individuals with disabilities and their families as they navigate services and systems.

VI. Analysis and Conclusion

A. Contextual Factors

The Virginia Living Well team, like several other grantees, has had to maintain project momentum while navigating 

numerous changes among state leadership and local providers. This contextual factor precedes the pandemic, but was 

nonetheless exacerbated by a rapid change in priorities as a result of COVID-19. Additionally, in response to the challenges 

presented by the DOJ settlement, the Virginia Living Well team works closely with the Regional Quality Councils to 

develop and implement trainings and interventions that are most effective and conducive to provider and community 

needs. 

B. Model Design

The Virginia Living Well team utilizes their strong relationships with diverse stakeholders across the state to expand the 

knowledge and skillset of individuals with disabilities and those who support them. By using varied data points gathered 

from multiple organizational and agency partners, the Virginia Living Well team developed a number of courses and 

trainings tailored to the needs of individuals with disabilities, family members, direct support professionals, providers, and 

state agencies.

C. Key Activities

In response to the impact of COVID-19, the Virginia Living Well team tailored existing grant initiatives and implemented 

new activities. By collecting COVID-19-related data from their provider partners, the Virginia Living Well team tracked 

if and how individuals with I/DD are accessing services during the pandemic. The Virginia Living Well team has several 

ongoing trainings for key players in the I/DD field. While some trainings are on-hold due to COVID-19, there remain 

online trainings and resources for individuals with I/DD, family members, direct support professionals, and providers. 

When appropriate, the Virginia Living Well team works with specialists to transform trainings originally intended to be 

held in-person to an online format that is effective, accessible, and sustainable. For example, the five pre-recorded modules 

for the Regional Quality Council training will ensure the availability of the content materials beyond the life of the grant. 

Additionally, the Virginia Living Well team employed innovative marketing strategies for trainings and courses by using 

social media and their relationship with local agencies to bring attention to the various initiatives, establishing a presence 

that will support continuation of Living Well objectives once the grant is over. Beyond adapting the format of delivery, 

the Virginia Living Well team modified some training content to take on a data-driven approach, both incorporating the 

requirements outlined by DOJ and enhancing a more scalable framework for future trainings.
Living Well Annual Report Volume II: Grantee Profiles 38

WISCONSIN

Living Well Grantee Profile

The Wisconsin Board for People with Developmental Disabilities (BPDD) received the five-year Living Well grant in 2018.

I. Grantee Information

The Wisconsin BPDD was established in 1970 through the national Developmental Disabilities Act of the same year and 

serves as the state’s developmental disabilities (DD) council. The Governor appoints BPDD’s board members, 60 percent of 

whom are people with intellectual and developmental disabilities (I/DD) and family members. The organization conducts 

outreach, funds local initiatives, and provides information and training to educate citizens about issues affecting people 

with disabilities. More than 70 percent of BPDD’s funds go to local projects and to advocate for better programs. At 

large, BPDD focuses on advocacy, capacity building, and systems change to improve self-determination, independence, 

productivity, and integration and inclusion for people with disabilities.

The Wisconsin BPDD supports initiatives related to the well-being of people with disabilities. These include administration 

of grants, including Employment First Partner and SPARKS grants; trainings on various topics, such as how to advocate for 

policies; self-advocate spotlights and leadership forums; conferences, including the Self-Determination Conference; and 

distribution of family navigators to provide intensive case management for tribal and Latinx families.

II. Grantee Partnerships

The Wisconsin BPDD partners with key stakeholders on their Living Well grant (collectively, the Wisconsin Living Well 

team) including, but not limited to, the Waisman Center, Disability Rights Wisconsin, the Arc Wisconsin, InControl 

Wisconsin, the Council on Quality and Leadership, People First Wisconsin, the state Department of Health Services (DHS), 

Adult Protective Services, Wisconsin Department of Justice (DOJ), managed care organizations, and Self-Directed Support 

Consultant Agencies.
Living Well Annual Report Volume II: Grantee Profiles 39

III. State Context

Variations in access to quality home and community-based services (HCBS) occur, in part, due to varying demographic, 

economic, political, and historical factors in each state. Key contextual factors are described here to better understand 

BPDD’s external conditions for their Living Well model. The COVID-19 pandemic rapidly evolved during the 2019-2020 

evaluation cycle with significant impact on the delivery of in-person HCBS and the health and safety of individuals with I/

DD. The pandemic response influenced both how and the extent to which grantees implemented grant activities as planned 

and the local and state context in which the grant is being implemented.

The Wisconsin Governor previously expressed interest in reducing abuse, neglect, and exploitation among people with 

disabilities and older adults. This interest provides an opportunity for the Wisconsin Living Well team to influence 

budgets and priorities; for example, the team provided recommendations for the Governor’s budget for 2021-2023. The 

recommendations include an emphasis on strengthening reporting and monitoring. The Wisconsin Living Well team 

anticipates COVID-19 will change the biennial budget significantly because of drastic tax shortfalls and added expenses. 

The Wisconsin Living Well team continues to look for opportunities for change without fiscal implications.

The Wisconsin Living Well team recently initiated a unique partnership with the Wisconsin DOJ. The Wisconsin DOJ 

launched a number of initiatives to address abuse and neglect, including obtaining grant funding for a hotline to report 

elder abuse. Wisconsin Living Well team members met with the Wisconsin Attorney General to share goals for the Living 

Well project and discuss strategies for reducing abuse, neglect, and exploitation. Future discussions will aim to hone in on 

opportunities for further collaboration, including expanding the hotline for vulnerable adults ages 18-65 and identifying 

and mapping the current incident response system across the state.
Living Well Annual Report Volume II: Grantee Profiles 40

IV. Model and Objectives

The Wisconsin Living Well model uses a multi-level approach: The Wisconsin Living Well team is leading statewide 

policy recommendations and advocacy while providing coaching and leadership to the stakeholder group and local pilot 

and mentor sites. The team is also developing a peer self- advocate leadership network to advise project activities and 

goals and serve as the training team on the project using the Safe and Free self-advocacy curriculum. The grant formed a 

consortium of stakeholders that meets three times a year to assist in the development of a sustainable models of capacity 

building and community monitoring. The consortium participants receive project updates from the pilot and mentor sites, 

self-advocates, and state agencies and are given the opportunity to share back information gathered around the project 

objectives. 

A group of pilot and mentor sites are equipping individuals with I/DD, families, and direct support professionals (DSPs) 

with skills and trainings to address health and safety needs identified through self-assessments conducted in partnership 

with Wisconsin Living Well team coaching staff. Each site is working with up to 20 individuals on this project. In addition, 

the mentor sites are participating in a learning collaborative with the pilot sites to provide insights and expertise.

The Wisconsin Living Well team’s model objectives are to:

1. Implement an intervention package in five pilot providers across the state;

2. Provide coaching to pilots to ensure full implementation and fidelity;

3. Create policy and practice recommendations based on pilot findings;

4. Develop a statewide peer leadership network to maximize independence and conduct health and safety monitoring; 

and

5. Determine a sustainable model of capacity building and community monitoring to benefit individuals with I/DD 

living in the community.

V. Key Activities by Core Components

A. Community Monitoring

Community Monitoring includes efforts to develop a comprehensive system to monitor the health and well-being of 

individuals with I/DD living in a variety of home and community-based settings. The following are key activities reported 

by the Wisconsin Living Well team during this evaluation period with the main goal of addressing this core component:

Key Activity: Develop Policy Recommendations

• The Wisconsin Living Well team established a policy team, which includes grant team members and representatives 

from stakeholders, to develop the policy recommendations to improve the health, well-being of people, and right 

of people with I/DD in Wisconsin. The team includes grant staff and grant partner representatives. The policy team 

conducted an environmental scan including reviewing other states’ approaches to abuse and neglect monitoring and 

reporting. Based on their research, the Wisconsin Living Well team is now working on policy recommendations to 

support a central reporting system, including statutory changes and new contractual language in the State long-term 

care contracts. The Wisconsin Living Well team is working to narrow these recommendations and determine which to 

forward to the Wisconsin DHS for inclusion in the state biennial budget.

• The policy team met with the Wisconsin Attorney General and DOJ to discuss their new hotline for reporting elder 

abuse and neglect. The Wisconsin Living Well team is working with the DOJ to expand the service to include reporting 

for abuse and neglect of vulnerable adults under age 59.

• A core component of Wisconsin’s Living Well project is the statewide consortium. The Wisconsin Living Well 

team holds three consortium meetings per year with project staff, project partners, community members, and 

representatives from each of the pilot sites, including the self-advocate leaders implementing the Safe and Free 

curriculum. The events allow for community conversations to take place on a range of topics including abuse and 

neglect systems in Wisconsin. Feedback during one meeting provided concrete actions steps to improve our systems in 
Living Well Annual Report Volume II: Grantee Profiles 41

Wisconsin, ways to break down the silos between systems, and possible policy recommendations. 

B. Community Capacity Building

Community Capacity Building includes efforts to increase the skills and knowledge of all individuals, families, and service 

providers in the HCBS system. The following are key activities reported by the Wisconsin Living Well team during this 

evaluation period with the main goal of addressing this core component:

Key Activity: Engage Pilot Sites 

and Implement Intervention Plans 

• The Wisconsin Living Well team recruited five pilot sites from across the state, most of which have recruited between 

10 and 20 participants, who are individuals with I/DD, each. The grant coach worked with the pilot sites to complete 

self-assessments about their organizations. The majority of participants completed Personal Outcome Measures 

interviews which the leadership team then analyzed. The Wisconsin Living Well team staff used this information 

to work with the pilot sites to develop and begin to implement intervention packages to begin addressing teamrecommended activities as well as their self-identified areas of need. The intervention packages include trainings for 

staff as well as individuals with I/DD. The leadership team held bi-monthly Learning Collaborative calls to connect 

pilot sites with mentor sites.

Key Activity: Develop the Safe and Free Curriculum 

• The Safe and Free Curriculum is being developed by the Wisconsin Living Well team and implemented at the Living 

Well pilot sites. The curriculum covers topics important for self-advocates to learn about their rights, how to avoid 

abuse, and how to have healthy relationships. The leadership team helped pilot sites connect with or recruit selfadvocate leaders to deliver the Safe and Free Curriculum trainings. 

• The Wisconsin Living Well team’s grant coach worked with People First Wisconsin and the self-advocate leaders 

to modify the curriculum for virtual training. The self-advocate leaders provided feedback on the modules of the 

curriculum and created new materials to make it more accessible to all people. The self-advocates also provided input 

to the Wisconsin Living Well team on how to best communicate changes and what new materials should be added to 

the training. The team created and distributed an updated virtual curriculum guide for self-advocate leaders. 

• The Wisconsin Living Well team and self-advocates worked together to modify the Safe and Free curriculum to a 

virtual format once COVID-19 stopped in person services. The Wisconsin Living Well team has further developed the 

role of the self-advocate leaders and included them in additional activities through the Self-Determination Channel 

and Living Well Wednesday presentations.

• The Wisconsin Living Well team created accessible evaluation tools based on what stakeholders want to learn from the 

pilot testing of the curriculum. Some of the tools were created to be completed by participants after the training. Other 

tools include a protocol to debrief the self-advocate trainers after each class. The Wisconsin Living Well evaluation 

team adapted the tools to fit the new virtual format of the curriculum.

Key Activity: Create and Distribute COVID-19 

Toolkit and Host Living Well Wednesdays 

• The Wisconsin Living Well team was in the process of creating an abuse and neglect reporting toolkit before 

COVID-19. The team took this initial document and developed a full toolkit to meet the needs of people with 

disabilities during COVID-19. The healthy, safe, and connected toolkit was an identified long-term goal of the grant 

outcomes. The Wisconsin Living Well team worked with self-advocates and other stakeholders to put together a plain 

language toolkit for use during COVID-19. The toolkit also led to the creation of several rights documents including 

rights during COVID-19, employment rights, and re-opening rights. 

• The Wisconsin Living Well team companioned the toolkit with live presentations, called Living Well Wednesdays, via 

Zoom and Facebook Live to provide information to a larger audience on ways to stay healthy, safe, and connected. 
Living Well Annual Report Volume II: Grantee Profiles 42

The team began broadcasting in early April every Wednesday on COVID-19 related topics and other topics of interest 

including employment, voting, and racial equity with an overall focus on rights. 

• The self-advocate leaders created plain language videos for the People First Self-Determination YouTube Channel to 

inform people with I/DD about the toolkit in a more accessible format and have presented alongside professionals and 

the Wisconsin Living Well team during Living Well Wednesdays.

Key Activity: Conduct Virtual Services Evaluation

• The Wisconsin Living Well team is conducting an evaluation of virtual services being offered in response to 

COVID-19 changes. The evaluation period ran from May to August and took place across 10 providers. Information 

was reported directly from provider agencies about what services were available, how the agencies were adapting 

and developing the services, and feedback the agencies were receiving about how the virtual services. While not all 

services can be delivered virtually, the Wisconsin Living Well team recognizes the important role of virtual services in 

the future. The evaluation will help identify best practices and the extent of the role of virtual services in the future. A 

final report will be shared with the DHS to be considered as part of a State telehealth policy on HCBS.

• This evaluation focuses on defining effectiveness for virtual services and implementing effective practices. The 

evaluation includes the full range of virtual programming offered by providers. For example, some providers are 

holding virtual programming sessions on specific topics once or twice a week while others are conducting activities 

on defined topics at a set time once a week, and still other providers are holding general social hours. Preliminary data 

from the virtual services evaluation indicated a positive participant response (506 end of session responses; includes 

duplicate participants): 99 percent are satisfied with the session and 98 percent report they learned more about the 

topics covered in the virtual service in which they participated. Another important element is that participants 

experience increased independence in the use of virtual service technology over time. Two-thirds of participants 

report using the technology to connect to others outside of the virtual service sessions.
Living Well Annual Report Volume II: Grantee Profiles 43

VI. Analysis and Conclusion

A. Contextual Factors

A lack of a statewide centralized reporting system in Wisconsin led the Wisconsin Living Well team to study and identify 

best practices and make recommendations to the state for policies and budget considerations. The Wisconsin Living Well 

team is also looking to take advantage of executive branch interest in reducing abuse and neglect to build a partnership 

with the Wisconsin DOJ. This relationship between the BPDD and DOJ will allow the Wisconsin Living Well team to 

ensure that work on reducing abuse and neglect continues beyond the grant period. 

B. Model Design

The Wisconsin Living Well team’s work is tiered, working with pilot sites to build, test, and implement action plans at a 

local level and various statewide partners to make policy recommendations for systems change at a statewide level. While 

policy updates and systems change take time, the Wisconsin Living Well team has used their grant to begin setting these 

processes in motion. In addition to these systems changes, the Wisconsin Living Well team and grant coach are working 

with pilot sites to enact immediate changes to build capacity among individuals with I/DD and the systems that serve 

them.

C. Key Activities

The Wisconsin Living Well team is utilizing five provider partners as pilot sites to identify needs and implement action 

plans that address common goals as well as goals that meet their needs. This model supports disability service providers 

and those they serve to build capacity by focusing on their local areas of need. The partnership with several other providers 

to serve as mentor sites and develop a learning collaborative has the potential to be a sustainable best practice if the mentor 

sites stay engaged and continue to learn and improve their services as well. 

Overall, improvements in service quality that pilot sites make by implementing their action plans should be sustainable 

beyond the life the grant. In addition, relationships between providers (both mentor and pilot sites) should continue 

beyond the grant as the Wisconsin Living Well team is working to build a sustainable community of practice. The 

Wisconsin Living Well team is working to build and develop tools that will support providers beyond the life of the grant 

and the support of the grant coach.