Expanding Integrated Employment in Wisconsin s New Managed Long-Term Care System: The Long-Awaited Arrival of The P

1. Wisconsin Department of Health Services Division of Long-Term Care Financial Support for the Task Force is provided by the Centers for Medicare and Medicaid, Medicaid Infrastructure Grant (MIG), CFDA No. 93.768, through DHS�s Office of Independence and Employment/Pathways to Independence. Expanding Integrated Employment in Wisconsin�s New Managed Long-Term Care System:The Long-Awaited Arrival of The Perfect Storm

3. Integrated Employment: Elements of the Perfect Storm Three key systems now focused on increasing integrated employment outcomes: Special Education Vocational Rehabilitation Long-Term Care

4. IEP Indicator #13: Every student, age 16 or older, who has an IEP is now expected to have a measurable post-secondary employment goal. DPI goal is 100% compliance with this federal indicator. Compliance involves the expectation that agencies which can pay for and provide services after graduation are invited to IEP meetings. Schools are expected to get consent from student/family to invite these agencies; document in the IEP the services that can be provided by each agency being invited; and show that the agencies were invited to the IEP.

5. IEP Indicator #14: Percent of youth who had IEP�s, are no longer in secondary school and who have been competitively employed, enrolled in some type of postsecondary education, or both, within one year of leaving high school. Competitive employment means work that is performed on full or part-time basis in an integrated setting where individual is compensated at or above minimum wage.

6. Vocational Rehabilitation: 1978: Rehab Act contained �feasibility requirement� 1992: Feasibility requirement repealed. All eligible individuals must be presumed able to benefit from VR services. 2001: RSA revised definition of what constitutes an employment outcome � eliminating sheltered workshops and other types of segregated settings.

7. Context for Positive Change in WI Long-Term Support System: Convergence of Two Major DHS Initiatives: Statewide expansion of the Family Care managed long-term care program Expansion of integrated employment opportunities for people with disabilities through the Pathways to Independence Medicaid Infrastructure Grant (MIG) initiative Shared goals of both initiatives To offer people with disabilities a greater depth and breadth of employment choices. To provide services that support employment and are readily accessible, high quality and cost effective.

8. Wisconsin Managed Care System: Umbrella Name: �Family Care� Includes: Family Care Program Partnership Program Alternative Option: IRIS (Self-Directed Supports Waiver)

9. Family Care: Program Features Family Care creates entitlement to community services. Waiting lists are eliminated within 24 months of start-up. Transition age individuals can apply at 17 yrs 9 months and begin receiving services at age 18. Significant new state dollars are being invested to match with federal dollars in order to provide adequate funding for a statewide system that will double in size. Reimbursement rates for regional managed care organizations are adjusted annually based on functional needs of individuals served and actual spending by MCOs in prior years. Choice of providers and services is required. There is flexibility in who can be paid to provide services, particularly with the self-directed supports option within Family Care. Outside Family Care, a Self-Directed Supports Waiver called IRIS now exists, if individuals wish to self-direct their entire long-term support budgets.

10. Family Care: Program Features that Support Expanded Employment Family Care includes transportation services which can be used to support employment participation, particularly in integrated settings. Family Care allows the flexibility to support a mix of employment and non-employment activities during an individual�s day or week so the individual does not have to choose between integrated employment (often part-time) and supports needed for other activities. Family Care does not include policies that create across-the-board caps on the number of hours of support or expenditures permitted for integrated employment.

11. The Managed Care and Employment Task Force (MCETF) Convened by Sinikka Santala, Administrator for the Division of Long-Term Care. Chaired by Fredi Bove, Deputy Administrator of the Division. 28 members, including wide range of stakeholders: MCOs, ADRCs, VR, DPI, consumers and family members, advocates, providers, employers, counties, and state agencies. Seven issue committees Listening sessions held June 16-27, 2008 Final report issued July 2008.

12. The Managed Care and Employment Task Force Final Report Download Full Report at: http://dhs.wisconsin.gov/WIpathways/

13. MCETF Final Report Highlights: 17 broad recommendation areas; each area has numerous specific recommendations. Initial Recommendation: that DHS adopt the following Policy on Employment to guide all system efforts related to expanding and improving employment opportunities in the context of Family Care expansion.

14. Policy Statement on Employment Among employment options, integrated employment offers people with disabilities the greatest access to full community inclusion and an array of employment choices equal to those available to citizens without disabilities. Integrated employment at a competitive wage offers individuals a meaningful path toward economic security and the respect and dignity associated with employment, which is enjoyed by working citizens without disabilities. Therefore, while always respecting individual, informed choice, because integrated employment provides access to the fullest range of employment choices and outcomes, and better opportunities for community integration and meaningful earnings for members, the managed care long-term care system should support integrated employment as the preferred employment option.

15. Implementation Mechanisms Dept plans to charge a body of external stakeholders with relevant expertise with monitoring progress and reviewing outcomes related to implementation of the recommendations. Will use a mechanism that involves DWD, former members of Task Force, experts on long-term care and others with employment expertise. Will have linkage to DHS Long Term Care Council, which oversees the Family Care program Dept is developing a multi-year work plan for comprehensive implementation, taking into account priorities and sequencing relationships between recommendations

16. Implementation Mechanisms: Resources Proposal made to Center for Medicaid Services for MIG funding to support implementation of MCETF recommendations. For 2009, total MIG award includes approximately $5 million dollars to be spent on activities related to implementation of MCETF recommendations.

17. The Perfect Storm Schools, VR and Long-Term Support Systems now share common goals and priorities regarding integrated employment. Individuals with significant disabilities are no longer wait-listed by any system. Can we find ways work together effectively?

18. Task Force Recommendations Focused on Transition: ADRC�s, DVR, DPI should collaborate in doing coordinated outreach to schools so that school system personnel assisting students transitioning out of the K-12 system are knowledgeable about the full range of employment options that can be supported by DVR and the long-term care system. Fully implement existing DHFS/DWD/DPI inter-agency agreement on youth in transition, and develop an inter-agency agreement for adults with key partners.

19. Task Force Recommendations Focused on Transition: Through joint efforts on staff training and related activities, DHS, DVR, DPI and DET should ensure their staff understand the programs, services and resources available through the other systems, and how all of these can be effectively braided and blended to provide needed supports to individuals pursuing integrated employment. DVR regional offices and MCO�s should consider appointing liaisons to facilitate coordination of service delivery to common customers.

20. Interagency Agreement for Transitioning Youth Agreement between DPI & DVR developed in 2004 to� fulfill mandates of IDEA and Rehab Act clarify agency roles establish suggested guidelines for working on transition activities New agreement signed in 2007 that included DHS and the changes made to IDEA http://dwd.wisconsin.gov/dvr/pdf_files/dpi_interagency_agreement.pdf

21. New Agreement will Benefit� Students w/disabilities transitioning from high school Parents of students w/disabilities Agency Representatives DVR counselors  Social Workers/ Case Managers ADRC Information & Assistance Specialists  Educators and others Establishes an important link/translation between the commitments at the high (Administrative) level to the local level. Collaboration of IEP, IPE and ISP. Shared values: Self directed/person centered least restrictive/most integrated settings. Establishes an important link/translation between the commitments at the high (Administrative) level to the local level. Collaboration of IEP, IPE and ISP. Shared values: Self directed/person centered least restrictive/most integrated settings.

22. What Agencies Agree To Do Training/professional development Share/collect information and data  Participate in and support, WSTI & START Invite stakeholders/agencies (w/consent)  Identify & include potential/active contacts

23. What Agencies Agree To Do Cont. Establish employment practice groups  Participate in Transition Advisory Councils  Sustain communication - importance of connecting to each other to provide & coordinate services  Collaborate to continue developing the TAG and other resources

24. Vision of Employment Improved career planning Improved wages Benefits/options counseling  More integrated settings Self-determination/empowerment Meaningful opportunities for work More employer & business partnerships Equal access & benefits Youth with disabilities will work! Others to include? Youth will have work experiences before leaving school (one of the single greatest indicators that youth will be gainfully employed as adults) Others to include? Youth will have work experiences before leaving school (one of the single greatest indicators that youth will be gainfully employed as adults)

25. Transition Action Guide Introductions/Preface Process Model  Roles and Responsibilities Youth Leadership  Successful Practices Commonly Asked Questions  Appendices/Glossary http://dwd.wisconsin.gov/dvr/pdf_files/tag.pdf Look through the guide Core Values key in forming relationships and sharing work The Transition process model greatest help to local districts & agencies Created the biggest change in practice and understanding in each other Successful practices If we build partnership on successful practice we have a much better chance of succeeding. This is a working draft and continues to grow and improve in focus Look through the guide Core Values key in forming relationships and sharing work The Transition process model greatest help to local districts & agencies Created the biggest change in practice and understanding in each other Successful practices If we build partnership on successful practice we have a much better chance of succeeding. This is a working draft and continues to grow and improve in focus

26. Transition Process Model Identify measurable post-school employment goals Provide information about services Refer to agencies when services may be needed

27. Transition Process Model Cont. Develop transition plans for jointly-served students Plan coordination for jointly-served students Implementation, review, and changes

28. Youth Leadership & Development See transitioned youth as �experts�  Include youth to identify issues, barriers Include youth in policy making Youth have many thoughts -- want to help Quality improves when youth involved More youth at the table than ever (committees, councils, presentations, IEP meetings, etc.) but still a long way to go. Adults are still learning that youth are capable of being at the table and contributing at all levels including in policy making decisions. Youth are still learning how to be active participants with their own voice. Progress � A few years ago, if you asked youth to raise their hands if they attended their IEP only a couple would go up. Today, almost all of them say they attend. Now, we�re working on if they participate in their IEP and more and more hands are going up for that too. Also, a few years ago, youth were rarely included in presentations on topics related to youth. Today, they are routinely thought of and asked to speak on panels. Nothing about us, without us � see next slide for the detail More youth at the table than ever (committees, councils, presentations, IEP meetings, etc.) but still a long way to go. Adults are still learning that youth are capable of being at the table and contributing at all levels including in policy making decisions. Youth are still learning how to be active participants with their own voice. Progress � A few years ago, if you asked youth to raise their hands if they attended their IEP only a couple would go up. Today, almost all of them say they attend. Now, we�re working on if they participate in their IEP and more and more hands are going up for that too. Also, a few years ago, youth were rarely included in presentations on topics related to youth. Today, they are routinely thought of and asked to speak on panels. Nothing about us, without us � see next slide for the detail

29. New Strategies to Expand Access to Integrated Employment Customized Employment Self-Employment Micro-Enterprise Traditional supported employment, including job carving will still be utilized. Prevocational services in sheltered workshops will still be an option, if people choose this after knowing and understanding all the options available.

30. Employment Myths and Facts Employment Myth: People with significant disabilities do not have skills or abilities that employers are interested in paying for. Employment Facts: If we use strategies other than assisting people to compete for advertised jobs, people with significant disabilities can contribute to the business community in a way that allows them to earn minimum wage or better. There is a business case for hiring people with disabilities.

31. Customized Employment Relies on a process of discovery, to determine the true strengths, abilities, and interests of a job seeker with complex and significant disabilities. Matches employer�s unmet needs with component skills and abilities of job seeker. Co-workers welcome individual because s/he is addressing unmet needs in the workplace or relieving them of some tasks. Support on the job is provided by the employer (to the extent its provided to any employee) and then supplemented through a job coach or through paying a co-worker for coaching support. Emphasis on involving family and friends in discovery process and in identifying potential employers to approach. With SDS within Family Care and with IRIS, there is no longer a need to use day programs or community rehab facilities unless that is how people want to spend their days. Family Care, IRIS and SDS offer people many new opportunities to obtain employment, create their own micro-enterprises, go on to secondary education, contribute to other organizations in their communities as a volunteer, create and keep assets and benefits � the list goes on.With SDS within Family Care and with IRIS, there is no longer a need to use day programs or community rehab facilities unless that is how people want to spend their days. Family Care, IRIS and SDS offer people many new opportunities to obtain employment, create their own micro-enterprises, go on to secondary education, contribute to other organizations in their communities as a volunteer, create and keep assets and benefits � the list goes on.

32. Customized Employment According to US/DOL: Customized employment means individualizing the employment relationship between employees and employers in ways that meet the needs of both. It is based on an individualized determination of the strengths, needs, and interests of the person with a disability, and is also designed to meet the specific needs of the employer.

33. All Employers Have Unmet Needs�Particularly in Tough Economic Times

34. Focus on Individual Interests, Natural Motivations and Component Skills

35. Some Customized Jobs Pay for Themselves�And Then Some!

36. Self-Employment and Micro-Enterprise Provides an option for a person to create their own work based on their interests, connections and skills. �The type of business that a person with a disability can operate is limited only by imagination� US Department of Labor Office of Disability Employment Policy Supported employment providers are developing the expertise to support people in self-employment and micro-enterprise. Micro-enterprise involves 1-5 individuals running a business together. Work hours are flexible; people can work from home.

37. The Value of High Expectations �The greatest danger may not be that our aim is too high and we miss it, but rather that it is too low and we reach it.� -Michelangelo

38. For More Information: Lisa Mills, Consultant, Pathways to Independence Lead Staff: Managed Care & Employment Task Force Lisa.Mills@dhs.wisconsin.gov (608) 225-4326 Jenny Neugart, Outreach Specialist, Pathways to Independence Jennifer.Neugart@dhs.wisconsin.gov (608) 266-8788