Missouri

Personal Assistant Services include a range of assistance for any activities of daily living (ADL) or instrumental activity of daily living (IADL) to enable individuals to complete tasks they are not able to do for themselves due to their disability. This may take the form of hands-on assistance (actually performing a task for the individual), cueing to the individual to perform a task, or performing the task for the individual if they are not able to do for themselves. Personal assistant services provide support and incidental teaching to assist the individual to participate fully in their home and community life. These supports can be provided in the participant’s own home, family home, and in the community, and always provided in the presence of the individual.

While Personal Assistant service is ordinarily provided on a one-to-one basis, personal assistance may be delivered to groups of individuals when it is determined to meet the individuals’ needs. With written approval from the Regional Office Director, personal assistant services may be delivered to groups of four (4) to six (6) persons when it is determined the needs of each individual in the group can be safely met.

Personal Assistant staff are required to be awake at all times. Personal Assistant Services may be provided on an episodic or continuing basis. Personal Assistant Services may be provided by an agency or as a self-directed option.

Relatives as Providers:

Relatives (parent, stepparent, foster parent, sibling, child (by blood, adoption, or marriage), spouse, grandparent, or grandchild) may be approved to provide personal assistant services through an agency or self-directed with exceptions listed below.

The following cannot be a provider of personal assistant services:

Individual’s spouse

Parent, step-parent, or foster parent of a minor child (under age 18)

The individual’s guardian

Self-directed supports designated representative or employer of record When a relative provides personal assistance, the ISP must reflect:

The individual is not opposed to the relative providing the services;

The planning team determines the paid relative providing the service best meets the individual’s needs;

The services to be provided are solely for the individual and not the benefit of the household/family unit;

A relative will only be paid for the hours authorized in the support plan and at no time can these exceed 40 hours per week. Any support provided above this amount would be considered a natural support or the unpaid care that a

family member would typically provide.

Difference between State Plan Personal Care and DD Waiver Personal Assistant Services:

Personal Assistant Service under the waiver differs in scope, nature, supervision arrangements, limitation of amount, and/or provider type from personal care services in the State Plan.

Personal Assistant Services (PA) differ from State Plan in the following ways:

PA may be provided in the community.

PA must always be provided in the presence of the individual receiving the service.

PA can provide support with medication administration and management. (Personal Assistant, Medical, unless self-directed)

PA can provide specialized healthcare and medical tasks or tasks requiring nursing delegation (Personal Assistant, Medical, unless self-directed)

PA may be self-directed through the use of a designated representative

When an individual’s need for personal assistant service can be met through the MO HealthNet state plan personal care program administered by the Division of Senior and Disability Services (DSDS) with the Missouri Department of Health and Senior Services (DHSS), he or she will not be eligible for Personal Assistant Services under the waiver, in accordance with the requirement that state plan services must be exhausted before waiver services can be provided.

After State Plan Personal Care services have been exhausted, DD Waiver Personal Assistant may be authorized when:

State plan limits on number of units for personal care are reached and more assistance with ADLs and/or IADLs is needed;

The individual has medical needs and they require a more highly trained personal assistant than is available under

state plan;

•When the personal assistant worker is related to the individual; or

•When the individual or family is directing the service through the Vendor Fiscal Employer Agent (VF/EA) Financial Management Services (FMS) contractor.

When waiver personal assistant is authorized to adults also eligible for state plan personal care, the Support coordinator must consult and coordinate the waiver support plan with the DSDS service authorization system.

Personal care services are provided to children with disabilities according to the federal mandates of the Early Periodic Screening, Diagnosis and Treatment (EPSDT) program. Personal Assistant needs for the eligible individual through EPSDT, as applicable, shall be accessed and utilized, in accordance with the requirement that state plan services must be exhausted before waiver services can be provided. Personal Assistant services authorized through the waiver shall not duplicate state plan personal care services. State plan personal care services for children are coordinated through the Bureau of Special Health Care Needs (BSHCN) through DHSS.

When waiver personal assistant is authorized for children also eligible for state plan personal care, the Support Coordinator must consult and coordinate with the BSHCN service authorization system.

Personal Assistant, Self-Directed option

Self-Directed Supports is an option of service delivery for individuals who wish to exercise more choice, control and authority over their supports.

Team Collaboration, Self-directed option

Team collaboration is available under Self-Directed Services only. Team collaboration allows the individual’s employees to participate in the Individual Support Plan and to meet as a team to ensure consistency in its implementation. A team meeting also can be convened by the individual or their designated representative for the purposes of discussing specific needs of the individual, the individualized progress towards outcomes, and other related concerns. Team collaboration can be included in the individual budget limited to 120 hours per plan year. Team collaboration is included in the rate for agency-based personal assistant services.

Personal Assistant, Medical option (Agency or Self-directed)

To assist in meeting the specialized medical needs for the individual as identified by the team and documented in the ISP, the following must have been met:

The interdisciplinary team has identified and outlined the need to pursue more intensive support for medically related issues;

•The need must be documented by a physician or advanced practice nurse and maintained on file;

Prior to approval of funding for medical personal assistance the ISP has gone through the local UR review process to determine the above have been completed.

Depending upon the scope of services, a registered professional nurse may be required to provide oversight in accordance with the Missouri Nurse Practice Act.

For individuals hospitalized, personal assistant services may be provided to assist with supports, supervision, communication, and any other supports that the hospital is unable to provide. The service will: be identified in an individual’s person-centered service plan; provided to meet needs of the individual that are not met through the provision of hospital services; not substitute for services that the hospital is obligated to provide through its conditions of participation or under Federal or State law, or under another applicable requirement; and be designed to ensure smooth transitions between acute care settings and home and community-based settings, and to preserve the individual’s functional abilities.

Limits on the amount, duration, or frequency of this service:

Individuals who receive Group Home, Individualized Supported Living, or Shared Living may not receive this service.

When this service is provided to minor children living with their parents or guardians, it shall not supplant the cost and provision of support ordinarily provided by parents to children without disabilities, educationally related services and support that is the responsibility of local education authorities, nor shall it supplant personal care through EPSDT.

Personal Services through EPSDT for eligible persons under age 21 shall be provided and utilized first before the waiver Personal Assistant Service is provided. Children have access to EPSDT services.

Children have access to any medically necessary preventive, diagnostic, and treatment services under Medicaid’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services to help meet children’s health and developmental needs. This includes age appropriate medical, dental, vision, and hearing screening services and diagnostic and treatment services to correct or ameliorate identified conditions. Supports provided by this waiver service is to improve and maintain the ability of the child to remain in and engage in community activities.

The services are limited to additional services not otherwise covered under the state plan, including EPSDT, but consistent with waiver objectives of avoiding institutionalization.

Individualized Skill Development (ISD) are individualized supports, delivered in a personalized manner, to support individuals who live in their own or family homes with acquiring, building, or maintaining complex skills necessary to maximize their personal independence. Teaching methods are individualized to what the participant wants to accomplish, learn and/or change based on the identified skill as developed in the person-centered planning process and provided in accordance with the individual support plan to achieve identified outcomes. Complex skills development include but is not limited to domestic and home maintenance, budgeting and money management, and using public transportation. Transportation costs related to the provision of this service in the community are included in the service rate. This is an episodic support of a clearly identified skill as developed through a person centered planning process and provided in accordance with the individual support plan the provider must document monthly progress toward achieving each skill identified in the individual support plan which shall include an annual review of progress towards the individual’s independent living goals. Personal Assistant services may be a component of Individualized Skill Development as necessary for the individual to participate in the service but may not comprise the entirety of the service. The UR process, authorized under 9 CSR 45-2.017 ensures all services authorized are necessary based on the needs of the individual.

Limits on the amount, duration, or frequency of this service:

Individuals who receive Group Home, Individualized Supported Living, or Shared Living may not receive this service This service is limited to 348 units (87 hours) a month. When this service is provided to minor children living with their parents or guardians, it shall not supplant the cost and provision of support ordinarily provided by parents to children without disabilities, educationally related services and support that is the responsibility of local education authorities, nor shall it supplant services through EPSDT This service may not be provided by a family member or guardian. Group Individualized Skill Development may not have more than 4 individuals in a group. This service is limited to additional services not otherwise covered under the state plan, including EPSDT, but consistent with waiver objectives of avoiding institutionalization.

Transportation services are also available under this waiver to support access to community activities as identified through the individual’s person-centered plan.

Personal Assistant Services include a range of assistance for any activities of daily living (ADL) or instrumental activity of daily living (IADL) to enable individuals to complete tasks they are not able to do for themselves due to their disability. This may take the form of hands on assistance (actually performing a task for the individual), cueing to the individual to perform a task, or performing the task for the individual if they are not able to do for themselves. Personal assistant services provide support and incidental teaching to assist the individual to participate fully in their home and community life. These supports can be provided in the participant’s own home, family home, and in the community, and always provided in the presence of the individual.

While Personal Assistant service is ordinarily provided on a one-to-one basis, personal assistance may be delivered to groups of individuals when it is determined to meet the individuals’ needs. With written approval from the Regional Office Director, personal assistant services may be delivered to groups of four (4) to six (6) persons when it is determined the needs of each individual in the group can be safely met.

Personal Assistant staff are required to be awake at all times. Personal Assistant Services may be provided on an episodic or continuing basis. Personal Assistant Services may be provided by an agency or as a self-directed option.

Relatives as Providers:

Relatives (parent, step-parent, foster parent, sibling, child (by blood, adoption, or marriage), spouse, grandparent, or grandchild) may be approved to provide personal assistant services through an agency or self-directed with exceptions listed below.

The following cannot be a provider of personal assistant services:

Individual’s spouse

Parent, step-parent, or foster parent of a minor child (under age 18)

The individual’s guardian

Self-directed supports designated representative or employer of record When a relative provides personal assistance, the ISP must reflect:

The individual is not opposed to the relative providing the services;

The planning team determines the paid relative providing the service best meets the individual’s needs;

The services to be provided are solely for the individual and not the benefit of the household/family unit;

A relative will only be paid for the hours authorized in the support plan and at no time can these exceed 40 hours per week. Any support provided above this amount would be considered a natural support or the unpaid care that a family member would typically provide.

Difference between State Plan Personal Care and DD Waiver Personal Assistant Services :

Personal Assistant Service under the waiver differs in scope, nature, supervision arrangements, limitation of amount, and/or provider type from personal care services in the State Plan.

Personal Assistant Services (PA) differ from State Plan in the following ways:

PA may be provided in the community.

PA must always be provided in the presence of the individual receiving the service.

PA can provide support with medication administration and management. (Personal Assistant, Medical, unless self-directed)

PA can provide specialized healthcare and medical tasks or tasks requiring nursing delegation (Personal Assistant, Medical, unless self-directed)

PA may be self-directed through the use of a designated representative

When an individual’s need for personal assistant service can be met through the MO HealthNet state plan personal care program administered by the Division of Senior and Disability Services (DSDS) with the Missouri Department of Health and Senior Services (DHSS), he or she will not be eligible for Personal Assistant Services under the waiver, in accordance with the requirement that state plan services must be exhausted before waiver services can be provided.

After State Plan Personal Care services have been exhausted, DD Waiver Personal Assistant may be authorized when:

State plan limits on number of units for personal care are reached and more assistance with ADLs and/or IADLs is needed;

The individual has medical needs and they require a more highly trained personal assistant than is available under state plan;

When the personal assistant worker is related to the individual ; or

When the individual or family is directing the service through the Vendor Fiscal Employer Agent (VF/EA) Financial Management Services (FMS) contractor.

When waiver personal assistant is authorized to adults also eligible for state plan personal care, the Support coordinator must consult and coordinate the waiver support plan with the DSDS service authorization system.

Personal care services are provided to children with disabilities according to the federal mandates of the Early Periodic Screening, Diagnosis and Treatment (EPSDT) program. Personal Assistant needs for the eligible individual through EPSDT, as applicable, shall be accessed and utilized, in accordance with the requirement that state plan services must be exhausted before waiver services can be provided. Personal Assistant services authorized through the waiver shall not duplicate state plan personal care services. State plan personal care services for children are coordinated through the Bureau of Special Health Care Needs (BSHCN) through DHSS.

When waiver personal assistant is authorized for children also eligible for state plan personal care, the Support Coordinator must consult and coordinate with the BSHCN service authorization system.

Personal Assistant, Self-Directed option

Self-Directed Supports is an option of service delivery for individuals who wish to exercise more choice, control and authority over their supports.

Team Collaboration, Self-directed option

Team collaboration is available under Self-Directed Services only. Team collaboration allows the individual’s employees to participate in the Individual Support Plan and to meet as a team to ensure consistency in its implementation. A team meeting also can be convened by the individual or their designated representative for the purposes of discussing specific needs of the individual, the individualized progress towards outcomes, and other related concerns. Team collaboration can be included in the individual budget limited to 120 hours per plan year. Team collaboration is included in the rate for agency-based personal assistant services.

Personal Assistant, Medical option (Agency or Self-directed)

To assist in meeting the specialized medical needs for the individual as identified by the team and documented in the ISP, the following must have been met:

The interdisciplinary team has identified and outlined the need to pursue more intensive support for medically related issues;

•The need must be documented by a physician or advanced practice nurse and maintained on file;

Prior to approval of funding for medical personal assistance the ISP has gone through the local UR review process to determine the above have been completed.

Depending upon the scope of services, a registered professional nurse may be required to provide oversight in accordance with the Missouri Nurse Practice Act .

For individuals hospitalized, personal assistant services may be provided to assist with supports, supervision, communication, and any other supports that the hospital is unable to provide. The service will: be identified in an individual’s person-centered service plan; provided to meet needs of the individual that are not met through the provision of hospital services; not substitute for services that the hospital is obligated to provide through its conditions of participation or under Federal or State law, or under another applicable requirement; and be designed to ensure smooth transitions between acute care settings and home and community-based settings, and to preserve the individual’s functional abilities.

Limits on the amount, duration, or frequency of this service:

Individuals who receive Group Home, Individualized Supported Living, or Shared Living may not receive this service. When this service is provided to minor children living with their parents or guardians, it shall not supplant the cost and provision of support ordinarily provided by parents to children without disabilities, educationally related services and support that is the responsibility of local education authorities, nor shall it supplant personal care through EPSDT Personal Services through EPSDT for eligible persons under age 21 shall be provided and utilized first before the waiver Personal Assistant Service is provided. Children have access to EPSDT services. Children have access to any medically necessary preventive, diagnostic, and treatment services under Medicaid’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services to help meet children’s health and developmental needs. This includes age appropriate medical, dental, vision, and hearing screening services and diagnostic and treatment services to correct or ameliorate identified conditions. Supports provided by this waiver service is to improve and maintain the ability of the child to remain in and engage in community activities. The services are limited to additional services not otherwise covered under the state plan, including EPSDT, but consistent with waiver objectives of avoiding institutionalization.

Prevocational Services provide one-to-one learning and group experiences to further develop an individual’s general, non-job-task-specific skills needed to succeed in competitive, integrated employment (work settings where compensation is at or above minimum wage). Services are expected to occur over a defined period of time with specific and measurable outcomes to be achieved. Services prepare the individual to attain the highest level of independence and autonomy in the most integrated employment setting aligned with the individual’s interests, abilities, and capabilities.

Prevocational services includes activities that are primarily directed at assisting an individual with developing non- job task specific skills that are associated with performing competitive work in community integrated employment. Providers of this service may coordinate, evaluate and communicate not only with the individual but, also with community businesses to develop unpaid work experiences. This service should be provided in the presence of the individual to the maximum extent possible and should be conducted in the community to the maximum extent possible but completion of activities without the presence of the individual should not be precluded.

Prevocational services may include volunteering, uncompensated work experience and compensated work experience settings to support the development of expanded habilitation skills. Any limitations on location or duration of these experiences are established and governed through the US Department of Labor (DOL) Fair Labor Standards Act and Wage and Hour Laws. It is the service provider’s responsibility to understand these industry specific term and act in accordance to DOL regulations.

Services may be provided in a community setting or at a certified or accredited facility of a qualified employment service provider. The setting for the delivery of services must be aligned with the individualized assessed need and that which is most conducive in developing the specific and measurable outcomes contained within the Individual Support Plan. Services cannot be provided within an individual’s residence.

Services are intended to develop and teach expanded habilitative skills that lead to competitive and integrated employment including, but not limited to:

Communication with supervisors, co-workers and customers

Work appropriate conduct, hygiene and dress

Workplace problem solving skills

Use of strategies, to include assistive technology, for task attendance and completion

Workplace safety skills

Mobility and motor skills training

Asset development and financial literacy

Vocational services, which are not covered through home and community based waivers, are job task specific skills training required by a participant for the primary purpose of completing those tasks for a specific facility based job or those delivered in a segregated setting. The distinction between vocational and pre-vocational services is that Prevocational Services are delivered for the purpose of furthering habilitation goals that will lead to greater opportunities for competitive integrated employment or further career advancement.

Participation in Prevocational Services is not a pre-requisite for supported employment services. Prevocational Services should only be authorized when an individual is otherwise unable to directly enter the general workforce as a result of an underdeveloped or undeveloped general, non-job-task-specific skill(s).

Prevocational Services can be provided in small groups not exceeding four (4) individuals at a time. The decision to provide services in a group setting must be based on individualized assessed need and be supported in the person centered plan as being the most autonomous setting which facilitates the highest levels of individual learning.

The provision of Prevocational Services is always delivered with the intention of developing skills which will lead to competitive integrated employment. Volunteering for personal reasons not related to future employment would not be Prevocational Services.

All Prevocational Services should be reviewed and considered as a component of an individual’s person-centered services and supports plan no less than annually, more frequently as necessary or as requested by the individual. These services and supports should be designed to support successful employment outcomes consistent with the individual’s goals.

Personal Assistant services may be a component of Prevocational service as necessary for the individual to

participate in the service but may not comprise the entirety of the service.

Transportation costs for the implementation of Prevocational Services are included in the unit rate.

Prevocational Services furnished under the waiver may not include services available under a program funded under section 110 of the Rehabilitation Act of 1973 and its amendments or section 602(16) and (17) of the Individuals with Disabilities Education Act (20 U.S.C. 1401(16 and 17)). Therefore, the case record for any individual receiving this service must document the individual is not eligible for, unable to access, exhausted services or otherwise inapplicable for the aforementioned programs as outlined in an interagency MOU between Vocational Rehabilitation and the Division of DD.

Prevocational services must comply with 42 CFR §440.180(c) (2) (i).

Outcomes expected for this service are as follows:

Monthly plan describing the progress on skill acquisition and ongoing development needed to be prepared for employment.

Service Documentation:

Providers of Prevocational Services must maintain an individualized plan and detailed record of activities by unit of service.

(PLEASE SEE MAIN SECTION B-OPTIONAL FOR THE ADDITIONAL INFORMATION ABOUT VIRTUAL DELIVERY OF SERVICE)

Limits on the amount, duration, or frequency of this service:

Must be authorized based upon individual need not to exceed 2,080 units per annual support plan year. Additional units may be approved by the Division’s Regional Director or designee in exceptional circumstances.

Supported employment is a support service to facilitate competitive work in an integrated work setting. The service must be identified in the individual’s service plan based upon an individualized assessed need which promotes the greatest degree of integration, independence and autonomy. Models of supported employment may include individual support or group support such as community business-based work groups and or mobile crews.

Individual and group services are defined separately below.

For those individuals whose individualized assessed need supports self-employment, Supported Employment Individual employment supports may include services and supports that assist the individual in achieving self- employment through the operation of a business; however, Medicaid funds may not be used to defray the expenses associated with starting up or operating a business. Assistance for self-employment may include ongoing assistance, counseling and guidance once the business has been launched.

Assistance for self-employment may include:

Aide to the individual in identifying potential business opportunities;

Assistance in the development of a business plan, including potential sources of business financing and other assistance in developing and launching a business; and

Identification of the supports that are necessary for the individual to operate the business.

Supported Employment- Individual Supported Employment

Individual Supported Employment services are the ongoing supports to individuals and their employers who, because of their disabilities, need intensive on-going support to maintain a job in competitive or customized employment, or self-employment, in an integrated work setting in the general workforce at or above the state’s minimum wage, at or above the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities. The outcome of this service is sustained paid employment at or above the minimum wage in an integrated setting in the general workforce, in a job that meets personal and career goals.

Supported Employment – Individual Supported Employment services may include:

On-the-job training in work and work-related skills; i.e. job coaching to facilitate the acquisition, and ongoing performance, of the essential functions of the job and the facilitation of natural supports (i.e. fading).

Ongoing retention, supervision and monitoring of the person’s performance; i.e. evaluating self-maintenance strategies, work production and the effectiveness of natural supports (i.e. fading) which promote the greatest degree of inclusion, integration and autonomy.

Training in related skills needed to retain employment; i.e. supporting and facilitating strategies which promote inclusion in the workplace based upon individualized assessed need such as using assistive devices, community resources and public transportation. This service should be provided in the presence of the individual to the maximum extent possible but completion of activities without the presence of the individual should not be precluded.

Supported Employment -Small Group Employment Support:

Group supported employment are services and training activities provided in regular community business and industry settings for groups of two (2) to four (4) workers with disabilities. Small group employment support does not include services provided in facility based work settings or non-integrated work settings (i.e. settings which physically and socially isolate individuals from other employees). Examples include mobile crews and other community business-based workgroups employing small groups of workers with disabilities in integrated competitive employment in the community. The outcome of this service is sustained paid employment, work experience leading to further career development and individual integrated community-based employment for which an individual is compensated at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities. An annual review must occur to determine if the employment setting optimizes, but does not regiment, individual initiative, autonomy and independence in making employment choices.

Supported Employment – Small Group Employment Supports may include:

On-the-job training in work and work-related skills; i.e. job coaching to facilitate the acquisition, and ongoing performance, of the essential functions of the job and the facilitation of natural supports (i.e. fading).

Ongoing supervision and monitoring of the person’s performance on the job; i.e. evaluating self-maintenance strategies, work production and the effectiveness of natural supports (i.e. fading) which promote the greatest degree of inclusion, integration and autonomy.

Training in related skills needed to retain individual integrated community-based employment; i.e. supporting

and facilitating strategies which promote attendance and social inclusion in the workplace based upon individualized assessed need such as using community resources and public transportation.

Additional Information about Supported Employment services:

Supported employment services must be provided in a manner that promotes integration into the workplace and interaction between individuals and people without disabilities in those workplaces while maintaining the individual’s rights of dignity, privacy and respect.

All Supported Employment service options should be reviewed and considered as a component of an individual’s person-centered services and supports plan no less than annually, more frequently as necessary or as requested by the individual. These services and supports should be designed to support successful employment outcomes consistent with the individual’s assessed goals, needs, interests and preferences. Supported Employment Group is not appropriate for individuals who demonstrate the capacity, ability and interest to work independently. An individual’s autonomy and independence to perform employment with the least amount of restrictions must be supported through the person centered planning process.

Supported Employment supports do not include payment for supervision, training, support and adaptations typically available to other workers without disabilities filling similar positions in the business or otherwise covered under the Americans with Disabilities Act.

Supported Employment may include assistance with reporting and managing earnings with Social Security and Medicaid.

However, Personal Assistance Service may not be used in lieu of Supported Employment services as defined above.

Personal Assistant services may be a component of Supported employment as necessary for the individual to participate in the service but may not comprise the entirety of the service.

Transportation costs are not included in the supported employment rate . Transportation is available as a separate service if necessary and able to be coordinated through the person centered planning team.

Supported Employment furnished under the waiver may not include services available under a program funded under section 110 of the Rehabilitation Act of 1973 and its amendments or section 602(16) and (17) of the Individuals with Disabilities Education Act (20 U.S.C. 1401(16 and 17)). Therefore, the case record for any individual receiving this service must document the individual is not eligible for, unable to access, exhausted services or otherwise inapplicable for the aforementioned programs as outlined in an interagency memorandum of understanding between Vocational Rehabilitation and the Division of Developmental Disabilities.

Federal Financial Participation (FFP) is not claimed for incentive payments, subsidies, or unrelated vocational training expenses such as the following:

Incentive payments made to an employer to encourage or subsidize the employer’s participation in a supported employment program; or

Payments that are passed through to users of supported employment programs.

Outcomes expected for this service are as follows:

Monthly retention plan describing the results of the professional observation and assessment of the individual and their current and needed paid/unpaid supports to sustain employment. The retention plan includes a summary of implementation strategies to maximize employment, independence, natural supports, job performance and addressing any identified potential risk associated with reduction of paid supports.

Service Documentation:

Providers of Supported Employment must maintain an individualized plan and detailed record of monthly activities by unit of service.

(PLEASE SEE MAIN SECTION B-OPTIONAL FOR THE ADDITIONAL INFORMATION ABOUT VIRTUAL DELIVERY OF SERVICE)

Limits on the amount, duration, or frequency of this service:

N/A

“Assistive technology” means a device, product system, or engineered solution whether acquired commercially, modified, or customized that addresses an individual’s needs and outcomes identified in his or her individual service plan. The service is for the direct benefit of the individual in maintaining or improving independence, functional capabilities, vocational skills, or community involvement. The individual’s person-centered planning team will ensure that the individual understands the use of technology, the individual/family has information needed in order to make an informed choice/consent, and that he/she understands privacy protections as documented in the approved ISP. The Support Coordinator and providers will share responsibility for monitoring privacy concerns. The ISP documents all back-up support plans based on the individual’s needs. The ISP will document who is responsible for the monitoring activity and if they are on-site or off-site.

Assistive technology must include at least one of the following components: (a) “Assistive technology consultation” means an evaluation of the assistive technology needs of an individual, including a functional evaluation of technologies available to address the individual’s assessed needs and support the individual to achieve outcomes identified in his or her individual service plan. (b) “Assistive technology equipment ” means the cost of leasing, purchasing, warranty at purchase or otherwise providing for the acquisition of equipment and may include engineering, designing, fitting, customizing, or otherwise adapting the equipment to meet an individual’s specific needs. Assistive technology equipment may include Personal Emergency Response Systems (PERS), Mobile Emergency Response Systems (MERS), Medication Reminder Systems (MRS) and equipment such as motion sensing system, live video feed, or live audio feed. Assistive technology cannot be accessed to purchase video monitors or cameras to be placed in bedrooms and bathrooms. (c) “Assistive technology service delivery” means monthly implementation of service and monitoring of the technology equipment and individual as necessary. (d) “Assistive technology support” is intended for education and training beyond that included in initial installation/training and routine service delivery questions and implementation that aids an individual in the use of assistive technology equipment as well as training for the individual’s family members, guardians, staff, or other persons who provide natural supports or paid services, employ the individual, or who are otherwise substantially involved in activities being supported by the assistive technology equipment. Assistive technology support may include, when necessary, coordination with complementary therapies or interventions and adjustments to existing assistive technology to ensure its ongoing effectiveness.

Limits on the amount, duration, or frequency of this service:

Assistive technology equipment does not include items otherwise available as environmental accessibility adaptations or specialized medical equipment and supplies.

Assistive technology consultation is limited to one per year. An exception may be extended if the participant is pursuing a new or additional type of technology in the same year.

Assistive technology support is limited to 40 hours per year.

The costs of all components of Assistive Technology equipment shall not exceed $9,000 per annual support plan year, per individual.

An individual cannot receive the Mobile Emergency Response Systems (MERS) and the Personal Emergency Response Systems (PERS) service at the same time.

The services under the Comprehensive Waiver are limited to additional services not otherwise covered under the state plan, including EPSDT.

Children have access to any medically necessary preventive, diagnostic, and treatment services under Medicaid’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services to help meet children’s health and developmental needs. This includes age appropriate medical, dental, vision, and hearing screening services and diagnostic and treatment services to correct or ameliorate identified conditions. Supports provided by this waiver service is to improve and maintain the ability of the child to remain in and engage in community activities.

When this service is provided to minor children living with their parents or guardians, it shall not supplant the cost and provision of support ordinarily provided by parents to children without disabilities, educationally related services and support that is the responsibility of local education authorities, nor shall it supplant services through EPSDT.

If a person’s need can’t be met within a limit, attempts will be made to locate another funding source or an exception may be approved by the director or designee to exceed the limit if exceeding the limit will result in decreased need (units) of one or more other waiver services. The service plan must document exceeding the limit for the service that will result in a decreased need of one or more other waiver services . If it is determined the needs of a significant number of individuals cannot be met within the limitation, an amendment will be requested to increase the amount

of the limitation.

Benefits Planning is a service designed to inform an individual about competitive integrated employment and assist them to assess if it will result in increased economic self-sufficiency and/or net financial benefit through the use of various work incentives. This service provides information to the participant regarding the full array of available work incentives for essential benefit programs including Supplemental Security Income, SSDI, Medicaid, Medicare, housing subsidies, food stamps, ABLE accounts, etc.

The service also will provide information, education, consultation and technical assistance to the individual regarding:

• Income reporting requirements for public benefit programs, including the Social Security Administration

• Formalized development of Plans for Achieving Self Sufficiency (PASS), Property Essential to Self-Support (PESS)

• Assistance with utilization of social security work incentives

• Coordination of Social Security and Medicaid work incentives and benefits support

• Individual benefit verification, consultation, education and ongoing analysis/planning.

Benefits Planning can be provided to individuals considering or seeking competitive integrated employment, career advancement or to individuals who need financial problem-solving assistance to maintain competitive integrated employment.

This service may include activity on behalf of the individual to assist in provision of the benefits planning service. The service can be provided in person or virtually based on the individual’s informed choice.

Benefits Planning may only be provided if a Certified Work Incentives Counselor through a Missouri-based Social Security Supported Work Incentives Planning and Assistance (WIPA) program were sought and it is documented by the Support Coordinator that such services were not available, accessible or applicable due to either ineligibility or because of wait lists that would result in services not being available within 30 calendar days (this is only required once per year; i.e., it

must be repeated if Benefits Planning is needed in a subsequent year).

(PLEASE SEE MAIN SECTION B-OPTIONAL FOR THE ADDITIONAL INFORMATION ABOUT VIRTUAL DELIVERY OF SERVICE)

Limits on the amount, duration, or frequency of this service:

Benefits Planning services are limited to a maximum of 60 units per in annual support plan for any combination of initial benefits planning, supplementary benefits planning when an individual is evaluating a job offer/promotion or a self-employment opportunity, or problem-solving assistance to maintain competitive integrated employment. Additional units may be approved by the Division’s Regional Director or designee in exceptional circumstances.

Career Planning is a comprehensive individualized service which supports a participant with vocational discovery, identification of career themes (pathways) and development of a plan to achieve competitive integrated or self- employment goals. The outcome of this service is documentation of the participant’s stated career objective and a completed career plan/discovery profile used to guide ongoing individual employment support needs.

Career Planning activities may include but are not limited to the coordination and delivery of:

Home and neighborhood observations

Job exploration

Job shadowing

Informational interviewing

Work specific review of assistive technology

Assessment of interests and skills

Labor market research

Vocational and job related discovery on asset development

Providers of this service may coordinate, evaluate and communicate not only with the individual but, also with their caregivers, support team, employers, teachers and others who can assist with discovering an individual’s skills, abilities, interests, preferences, conditions and needs. This support and evaluation should be provided in the presence of the individual to the maximum extent possible and should be conducted in the community to the maximum extent possible; but, completion of activities in the home or without the presence of the individual is not precluded.

If an individual is employed, career planning may be used to explore other ongoing competitive employment career objectives which are consistent with the person’s skills and interests or explore advancement opportunities in his or her chosen career.

Career Planning should be reviewed and considered as a component of an individual’s person-centered services and supports plan no less than annually, more frequently as necessary or as requested by the individual. These services and supports should be designed to support successful employment outcomes consistent with the individual’s goals.

Career Planning furnished under the waiver may not include services available under a program funded under section 110 of the Rehabilitation Act of 1973 and its amendments or section 602(16) and (17) of the Individuals with Disabilities Education Act (20 U.S.C. 1401(16 and 17)). Therefore, the case record for any individual receiving this service must document the individual is not eligible for, unable to access, exhausted services or otherwise inapplicable for the aforementioned programs as outlined in an interagency MOU between Vocational Rehabilitation and the Division of DD.

Transportation costs for the implementation of Career Planning services are included in the unit rate.

Personal care assistance may be provided to support an individual while receiving this service, but may not comprise the entirety of the service.

Outcomes expected for this service are as follows:

An identified career path and profile which includes the individual’s needs, interests, strengths, natural supports and characteristics of potential work environments and a plan specifying actions necessary to achieve the individual’s

career goals.

Limits on the amount, duration, or frequency of this service:

Career Planning is intended to be time-limited. Services should be authorized through person centered employment planning based upon individualized assessed need not to exceed 240 units of services within annual support plan. Additional units may be approved by the Division’s Regional Director or designee in exceptional circumstances.

Community Networking, formerly known as Community Integration coordinates and provides support for valued and active participation in integrated activities that build on the person’s interests, preferences, gifts, and strengths while reflecting the person’s goals with regard to community involvement and membership.

Community Networking services are designed to increase an individual’s connection to and engagement in formal and informal community supports. Services are designed to develop flexible, sustainable, and supportive community resources and relationships. Individuals are introduced to community resources and supports that are available in their area and supported to develop skills that will facilitate integration into their community. Outcomes for this service include positive relationships, valued community roles, and involvement in preferred community activities/organizations/groups/projects/other resources. Community Networking outcomes are developed through a person centered planning process and provided in accordance with the individual support plan.

Expectations are for paid supports to be decreased and transitioned to natural supports over time when possible. Community Networking is not intended or designed to be used in employment settings.

Personal Assistant services may be a component of Community Networking as necessary for the individual to participate in the service but may not comprise the entirety of the service.

Transportation costs related to the provision of this service in the community are included in the service rate.

Limits on the amount, duration, or frequency of this service:

This service is limited to 432 units (108 hours) per month. Individuals who receive Group Home, Individualized Supported Living, or Shared Living may not receive this service. Group Community Networking may not exceed 4 individuals per staff person.

Individualized Skill Development (ISD) are individualized supports, delivered in a personalized manner, to support individuals who live in their own or family homes with acquiring, building, or maintaining complex skills necessary to maximize their personal independence. Teaching methods are individualized to what the participant wants to accomplish, learn and/or change based on the identified skill as developed in the person-centered planning process and provided in accordance with the individual support plan to achieve identified outcomes. Complex skills development include but is not limited to domestic and home maintenance, budgeting and money management, and using public transportation. Transportation costs related to the provision of this service in the community are included in the service rate. This is an episodic support of a clearly identified skill as developed through a person centered planning process and provided in accordance with the individual support plan the provider must document monthly progress toward achieving each skill identified in the individual support plan which shall include an annual review of progress towards the individual’s independent living goals. Personal Assistant services may be a component of Individualized Skill Development as necessary for the individual to participate in the service but may not comprise the entirety of the service. The UR process, authorized under 9 CSR 45-2.017 ensures all services authorized are necessary based on the needs of the individual.

Limits on the amount, duration, or frequency of this service:

Individuals who receive Group Home, Individualized Supported Living, or Shared Living may not receive this service This service is limited to 348 units (87 hours) a month. When this service is provided to minor children living with their parents or guardians, it shall not supplant the cost and provision of support ordinarily provided by parents to children without disabilities, educationally related services and support that is the responsibility of local education authorities, nor shall it supplant services through EPSDT This service may not be provided by a family member or guardian. Group Individualized Skill Development may not have more than 4 individuals in a group. This service is limited to additional services not otherwise covered under the state plan, including EPSDT, but consistent with waiver objectives of avoiding institutionalization.

Job Development is a support service to facilitate competitive work in an individual integrated work setting. The service must be identified in the individual’s service plan based upon an individualized assessed need which promotes the greatest degree of integration, independence and autonomy.

Job Development services are the supports to individuals who, because of the disabilities, will need assistance with obtaining individual competitive or customized employment in an integrated work setting in the general workforce at or above the state’s minimum wage, at or above the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities. The outcome of this service is the acceptance of an employment offer in a job that meets personal and career goals.

Job Development services may include:

Application completion assistance with the individual,

Job interviewing activities with the individual,

Completion of job analysis and/or task analysis with or without the presence of the individual based upon individualized need,

Negotiation with prospective employers and education of prospective employers of their role in promoting full inclusion with or without the presence of the individual based upon individualized need.

Consultation with the prospective employer on the use of assistive technology to promote greater autonomy and independence in the potential workplace,

Consultation and negotiation of work hours, wages and earnings.

Additional Information about Job Development services:

Job Development services must be provided in a manner that promotes integration into the workplace and interaction between individuals and people without disabilities in those workplaces while maintaining the individual’s rights of dignity, privacy and respect.

This service and support should be designed to support a successful employment outcome consistent with the individual’s assessed goals, needs, interests and preferences. An individual’s autonomy and independence to perform employment with the least amount of restrictions must be supported through the person centered planning process.

Job Development should be reviewed and considered as a component of an individual’s person-centered services and supports plan no less than annually, more frequently as necessary or as requested by the individual.

Job Development furnished under the waiver may not include services available under a program funded under section 110 of the Rehabilitation Act of 1973 and its amendments or section 602(16) and (17) of the Individuals with Disabilities Education Act (20 U.S.C. 1401(16 and 17)). Therefore, the case record for any individual receiving this service must document the individual is not eligible for, unable to access, exhausted services or otherwise inapplicable for the aforementioned programs as outlined in an interagency MOU between Vocational Rehabilitation and the Division of DD.

Personal care assistance may be provided to support an individual while receiving this service, but may not comprise the entirety of the service.

Transportation costs are included in the implementation of Job Development service.

FFP is not claimed for incentive payments, subsidies, or unrelated vocational training expenses such as the following:

Incentive payments made to an employer to encourage or subsidize the employer’s participation in a supported employment program; or

Payments that are passed through to users of community employment programs.

Outcomes expected for this service are as follows:

A job retention plan to include job title, wages, projected average number of hours to be worked weekly and recommended implementation strategies for paid/natural supports regarding unmet needs (i.e. personal assistance, transportation, skill acquisition, employment onboarding, workplace integration, etc.).

Service Documentation:

Providers of Job Development must maintain an individualized plan and detailed record of activities by unit of service.

(PLEASE SEE MAIN SECTION B-OPTIONAL FOR THE ADDITIONAL INFORMATION ABOUT VIRTUAL DELIVERY OF SERVICE)

Limits on the amount, duration, or frequency of this service:

Job Development is intended to be time-limited. Services should be authorized through person centered employment planning based upon individualized assessed need not to exceed 240 units of services within an annual support plan. Additional units may be approved by the Division’s Regional Director or designee in exceptional circumstances.

Transportation services are also available under this waiver to support access to community activities as identified through the individual’s person-centered plan.

Personal Assistant Services include a range of assistance for any activities of daily living (ADL) or instrumental activity of daily living (IADL) to enable individuals to complete tasks they are not able to do for themselves due to their disability. This may take the form of hands on assistance (actually performing a task for the individual), cueing to the individual to perform a task, or performing the task for the individual if they are not able to do for themselves. Personal assistant services provide support and incidental teaching to assist the individual to participate fully in their home and community life. These supports can be provided in the participant’s own home, family home, and in the community, and always provided in the presence of the individual.

While Personal Assistant service is ordinarily provided on a one-to-one basis, personal assistance may be delivered to groups of individuals when it is determined to meet the individuals’ needs. With written approval from the Regional Office Director, personal assistant services may be delivered to groups of four (4) to six (6) persons when it is determined the needs of each individual in the group can be safely met.

Personal Assistant staff are required to be awake at all times. Personal Assistant Services may be provided on an episodic or continuing basis. Personal Assistant Services may be provided by an agency or as a self-directed option.

Relatives as Providers:

Relatives (parent, step-parent, foster parent, sibling, child (by blood, adoption, or marriage), spouse, grandparent, or grandchild) may be approved to provide personal assistant services through an agency or self-directed with exceptions listed below.

The following cannot be a provider of personal assistant services:

Individual’s spouse

Parent, step-parent, or foster parent of a minor child (under age 18)

The individual’s guardian

Self-directed supports designated representative or employer of record When a relative provides personal assistance, the ISP must reflect:

The individual is not opposed to the relative providing the services;

The planning team determines the paid relative providing the service best meets the individual’s needs;

The services to be provided are solely for the individual and not the benefit of the household/family unit, and otherwise is above and beyond typical activities family members provide for another adult family member without a disability.

A relative will only be paid for the hours authorized in the support plan and at no time can these exceed 40 hours per week. Any support provided above this amount would be considered a natural support or the unpaid care that a family member would typically provide.

Difference between State Plan Personal Care Services and DD Waiver Personal Assistant Services

Personal Assistant Service under the waiver differs in scope, nature, supervision arrangements, limitation of amount, and/or provider type from personal care services in the State Plan.

Personal Assistant Services (PA) differ from State Plan in the following ways:

PA may be provided in the community.

PA must always be provided in the presence of the individual receiving the service.

PA can provide support with medication administration and management. (Personal Assistant, Medical , unless self-directed)

PA can provide specialized healthcare and medical tasks or tasks requiring nursing delegation (Personal Assistant, Medical, unless self-directed)

PA may be self-directed through the use of a designated representative

When an individual’s need for personal assistant service can be met through the MO HealthNet state plan personal care program administered by the Division of Senior and Disability Services (DSDS) with the Missouri Department of Health and Senior Services (DHSS), he or she will not be eligible for Personal Assistant Services under the waiver, in accordance with the requirement that state plan services must be exhausted before waiver services can be provided.

After State Plan Personal Care services have been exhausted, DD Waiver personal assistant may be authorized when:

State plan limits on number of units for personal care are reached and more assistance with ADLs and/or IADLs is needed;

The individual has medical needs and they require a more highly trained personal assistant than is available under state plan;

When the personal assistant worker is related to the individual; or

When the individual or family is directing the service through the Vendor Fiscal Employer Agent (VF/EA)

Financial Management Services (FMS) contractor.

When waiver personal assistant is authorized to adults also eligible for state plan personal care, the Support coordinator must consult and coordinate the waiver support plan with the DSDS service authorization system. Personal care services are provided to children with disabilities according to the federal mandates of the Early Periodic Screening, Diagnosis and Treatment (EPSDT) program. Personal Assistant needs for the eligible individual through EPSDT, as applicable, shall be accessed and utilized, in accordance with the requirement that state plan services must be exhausted before waiver services can be provided. Personal Assistant services authorized through the waiver shall not duplicate state plan personal care services. State plan personal care services for children are coordinated through the Bureau of Special Health Care Needs (BSHCN) through DHSS.

When waiver personal assistant is authorized for children also eligible for state plan personal care, the Support Coordinator must consult and coordinate with the BSHCN service authorization system.

Personal Assistant, Self-Directed option

Self-Directed Supports is an option of service delivery for individuals who wish to exercise more choice, control and authority over their supports.

Team Collaboration, Self-directed option

Team collaboration is available under Self-Directed Services only. Team collaboration allows the individual’s employees to participate in the Individual Support Plan and to meet as a team to ensure consistency in its implementation. A team meeting also can be convened by the individual or their designated representative for the purposes of discussing specific needs of the individual, the individualized progress towards outcomes, and other related concerns. Team collaboration can be included in the individual budget limited to 120 hours per plan year. Team collaboration is included in the rate for agency-based personal assistant services.

Personal Assistant, Medical option (Agency or Self-directed)

To assist in meeting the specialized medical needs for the individual as identified by the team and documented in the ISP, the following must have been met:

The interdisciplinary team has identified and outlined the need to pursue more intensive support for medically related issues;

The need must be documented by a physician or advanced practice nurse and maintained on file;

Prior to approval of funding for medical personal assistance the ISP has gone through the local UR review process to determine the above have been completed.

Depending upon the scope of services, a registered professional nurse may be required to provide oversight in accordance with the Missouri Nurse Practice Act.

For individuals hospitalized, personal assistant services may be provided to assist with supports, supervision, communication, and any other supports that the hospital is unable to provide. The services will: be identified in an individual’s person-centered service plan; provided to meet needs of the individual that are not met through the provision of hospital services; not substitute for services that the hospital is obligated to provide through its conditions of participation or under Federal or State law, or under another applicable

requirement; and be designed to ensure smooth transitions between acute care settings and home and community- based settings, and to preserve the individual’s functional abilities.

Limits on the amount, duration, or frequency of this service:

Individuals who receive Group Home, Individualized Supported Living, or Shared Living may not receive this service. When this service is provided to minor children living with their parents or guardians, it shall not supplant the cost and provision of support ordinarily provided by parents to children without disabilities, educationally related services and support that is the responsibility of local education authorities nor shall it supplant personal care through EPSDT. Personal Care services through EPSDT for eligible persons under age 21 shall be provided and utilized first before the waiver Personal Assistant service is provided. Children have access to EPSDT services. Children have access to any medically necessary preventive, diagnostic, and treatment services under Medicaid’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services to help meet children’s health and developmental needs. This includes age appropriate medical, dental, vision, and hearing screening services and diagnostic and treatment services to correct or ameliorate identified conditions. Supports provided by this waiver service is to improve and maintain the ability of the child to remain in and engage in community activities. The services are limited to additional services not otherwise covered under the state plan, including EPSDT, but consistent with waiver objectives of avoiding institutionalization.

Prevocational Services provide one-to-one learning and group experiences to further develop an individual’s general, non-job-task-specific skills needed to succeed in competitive, integrated employment (work settings where compensation is at or above minimum wage). Services are expected to occur over a defined period of time with specific and measurable outcomes to be achieved.

Services prepare the individual to attain the highest level of independence and autonomy in the most integrated employment setting aligned with the individual’s interests, abilities, and capabilities.

Prevocational services includes activities that are primarily directed at assisting an individual with developing non- job task specific skills that are associated with performing competitive work in community integrated employment. Providers of this service may coordinate, evaluate and communicate not only with the individual but, also with community businesses to develop unpaid work experiences. This service should be provided in the presence of the individual to the maximum extent possible and should be conducted in the community to the maximum extent possible but completion of activities without the presence of the individual should not be precluded.

Prevocational services may include volunteering, uncompensated work experience and compensated work experience settings to support the development of expanded habilitation skills. Any limitations on location or duration of these experiences are established and governed through the US Department of Labor (DOL) Fair Labor Standards Act and Wage and Hour Laws. It is the service provider’s responsibility to understand these industry specific term and act in accordance to DOL regulations.

Services may be provided in a community setting or at a certified or accredited facility of a qualified employment service provider. The setting for the delivery of services must be aligned with the individualized assessed need and that which is most conducive in developing the specific and measurable outcomes contained within the individual support plan. Services cannot be provided within an individual’s residence.

Services are intended to develop and teach expanded habilitative skills that lead to competitive and integrated employment including, but not limited to:

Communication with supervisors, co-workers and customers; Workplace appropriate conduct, hygiene and dress; Workplace problem solving skills; Use of strategies to include assistive technology for task attendance and completion; Workplace safety skills; Mobility and motor skills training; Asset development and financial literacy

Vocational services, which are not covered through home and community based waivers, are job task specific skills training required by a participant for the primary purpose of completing those tasks for a specific facility based job or those delivered in a segregated setting. The distinction between vocational and pre-vocational services is that Prevocational Services are delivered for the purpose of furthering habilitation goals that will lead to greater opportunities for competitive integrated employment or further career advancement.

Participation in Prevocational Services is not a pre-requisite for supported employment services. Prevocational services should only be authorized when an individual is otherwise unable to directly enter the general workforce as a result of an underdeveloped or undeveloped general, non-job-task-specific skill(s).

Prevocational services can be provided in small groups not exceeding four (4) individuals at a time. The decision to provide services in a group setting must be based on individualized assessed need and be supported in the person centered plan as being the most autonomous setting which facilitates the highest levels of individual learning.

The provision of Prevocational Services is always delivered with the intention of developing skills which will lead to competitive integrated employment. Volunteering for personal reasons not related to future employment would not be Prevocational Services.

All prevocational services should be reviewed and considered as a component of an individual’s person-centered services and supports plan no less than annually, more frequently as necessary or as requested by the individual.

These services and supports should be designed to support successful employment outcomes consistent with the individual’s goals. Personal assistance may be a component of prevocational services as necessary for the individual to participate i the service but may not comprise the entirety of the service.

Transportation costs for the implementation of Prevocational Services are included in the unit rate.

Prevocational Services furnished under the waiver may not include services available under a program funded under section 110 of the Rehabilitation Act of 1973 and its amendments or section 602(16) and (17) of the Individuals with Disabilities Education Act (20 U.S.C. 1401(16 and 17)). Therefore, the case record for any individual receiving this service must document the individual is not eligible for, unable to access, exhausted services or otherwise inapplicable for the aforementioned programs as outlined in an MOU between vocational rehabilitation and the Division of DD.

Prevocational services must comply with 42 CFR §440.180(c) (2) (i).

Outcomes expected for this service are as follows

Monthly plan describing the progress on skill acquisition and ongoing development needed to be prepared for employment.

Service Documentation:

Providers of Prevocational Services must maintain an individualized plan and detailed record of activities by unit of service.

(PLEASE SEE MAIN SECTION B-OPTIONAL FOR THE ADDITIONAL INFORMATION ABOUT VIRTUAL DELIVERY OF SERVICE)

Limits on the amount, duration, or frequency of this service:

Must be authorized based upon individual need not to exceed 2,080 units per annual support plan. Additional units may be approved by the Division’s Regional Director or designee in exceptional circumstances.

Supported employment is a support service to facilitate competitive work in an integrated work setting. The service must be identified in the individual’s service plan based upon an individualized assessed need which promotes the greatest degree of integration, independence and autonomy. Models of supported employment may include individual support or group support such as community business-based work groups and/or mobile crews.

Individual and group services are defined separately below.

For those individuals whose individualized assessed need supports self-employment, Supported Employment Individual employment supports may include services and supports that assist the individual in achieving self- employment through the operation of a business; however, Medicaid funds may not be used to defray the expenses associated with starting up or operating a business. Assistance for self-employment may include ongoing assistance, counseling, and guidance once the business has been launched.

Assistance for self-employment may include:

Aide to the individuals in identifying potential business opportunities;

Assistance in the development of a business plan, including potential sources of business financing and other assistance in developing and launching a business; and

Identification of the supports that are necessary for the individual to operate the business.

Supported Employment- Individual Supported Employment

Individual Supported Employment services are the ongoing supports to individuals and their employers who, because of their disabilities, need intensive on-going support to maintain a job in competitive or customized employment, or self-employment, in an integrated work setting in the general workforce at or above the state’s minimum wage, at or above the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities. The outcome of this service is sustained paid employment at or above the minimum wage in an integrated setting in the general workforce, in a job that meets personal and career goals.

Supported Employment – Individual Supported Employment services may include:

On-the-job training in work and work-related skills; i.e. job coaching to facilitate the acquisition, and ongoing performance, of the essential functions of the job and the facilitation of natural supports (i.e. fading).

Ongoing retention, supervision and monitoring of the person’s performance; i.e. evaluating self-maintenance strategies, work production and the effectiveness of natural supports (i.e. fading) which promote the greatest degree of inclusion, integration and autonomy.

Training in related skills needed to retain employment; i.e. supporting and facilitating strategies which promote inclusion in the workplace based upon individualized assessed need such as using assistive devices, community resources and public transportation. This service should be provided in the presence of the individual to the maximum extent possible but completion of activities without the presence of the individual should not be precluded.

Supported Employment -Small Group Employment Support:

Group supported employment are services and training activities provided in regular community business and industry settings for groups of two (2) to four (4) workers with disabilities. Small group employment support does not include services provided in facility based work settings or non-integrated work setting (i.e. settings which physically and socially isolate individuals from other employees). Examples include mobile crews and other community business-based workgroups employing small groups of workers with disabilities in integrated competitive employment in the community. The outcome of this service is sustained paid employment and work experience leading to further career development and individual integrated community-based employment for which an individual is compensated at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities. An annual review must occur to determine if the employment setting optimizes, but does not regiment, individual initiative, autonomy and independence in making employment choices.

Supported Employment – Small Group Employment Supports may include:

On-the-job training in work and work-related skills; i.e. job coaching to facilitate the acquisition, and ongoing performance, of the essential functions of the job and the facilitation of natural supports (i.e. fading).

Ongoing supervision and monitoring of the person’s performance on the job; i.e. evaluating self-maintenance strategies, work production and the effectiveness of natural supports (i.e. fading) which promote the greatest degree of inclusion, integration and autonomy.

Training in related skills needed to retain individual integrated community-based employment; i.e. supporting and facilitating strategies which promote attendance and social inclusion in the workplace based upon individualized assessed need such as using community resources and public transportation.

Additional Information about Supported Employment services:

Supported employment services must be provided in a manner that promotes integration into the workplace and interaction between individuals and people without disabilities in those workplaces while maintaining the individual’s rights of dignity, privacy and respect.

All Supported Employment service options should be reviewed and considered as a component of an individual’s person-centered services and supports plan no less than annually, more frequently as necessary or as requested by the individual. These services and supports should be designed to support successful employment outcomes consistent with the individual’s assessed goals, needs, interests and preferences. Supported Employment Group is not appropriate for individuals who demonstrate the capacity, ability and interest to work independently. An individual’s autonomy and independence to perform employment with the least amount of restrictions must be supported through the person centered planning process.

Supported Employment supports do not include payment for supervision, training, support and adaptations typically available to other workers without disabilities filling similar positions in the business or otherwise covered under the Americans with Disabilities Act.

Supported Employment may include assistance with reporting and managing earnings with Social Security and Medicaid.

Personal Assistance may be a component of supported employment as necessary for the individual to participate in the service but may not comprise the entirety of the service.

Transportation costs are not included in the supported employment rate. Transportation is available as a separate service if necessary and able to be coordinated through the person centered planning team.

Supported Employment furnished under the waiver may not include services available under a program funded under section 110 of the Rehabilitation Act of 1973 and its amendments or section 602(16) and (17) of the Individuals with Disabilities Education Act (20 U.S.C. 1401(16 and 17)). Therefore, the case record for any individual receiving this service must document the individual is not eligible for, unable to access, exhausted services or otherwise inapplicable for the aforementioned programs as outlined in an interagency memorandum of understanding between Vocational Rehabilitation and the Division of Developmental Disabilities.

Federal Financial Participation (FFP) is not claimed for incentive payments, subsidies, or unrelated vocational training expenses such as the following:

Incentive payments made to an employer to encourage or subsidize the employer’s participation in a supported employment program; or

Payments that are passed through to users of supported employment programs.

Outcomes expected for this service are as follows:

Monthly retention plan describing the results of the professional observation and assessment of the individual and their current and needed paid/unpaid supports to sustain employment. The retention plan includes a summary of implementation strategies to maximize employment, independence, natural supports, job performance and addressing any identified potential risk associated with reduction of paid supports.

Service Documentation:

Providers of Supported Employment must maintain an individualized plan and detailed record of monthly activities by unit of service.

(PLEASE SEE MAIN SECTION B-OPTIONAL FOR THE ADDITIONAL INFORMATION ABOUT VIRTUAL DELIVERY OF SERVICE)

Limits on the amount, duration, or frequency of this service:

N/A

“Assistive technology” means a device, product system, or engineered solution whether acquired commercially, modified, or customized that addresses an individuals’ needs and outcomes identified in his or her individual service plan. The service is for the direct benefit of the individual in maintaining or improving independence, functional capabilities, vocational skills, or community involvement.

The individual’s person-centered planning team will ensure that the individual understands the use of technology, the individual/family has information needed in order to make an informed choice/consent and that he/she understands privacy protections as documented in the approved ISP. The Support Coordinator and providers will share responsibility for monitoring privacy concerns. The ISP documents all back-up support plans based on the individual’s needs. The ISP will document who is responsible for the monitoring activity and if they are on-site or off-site.

Assistive technology must include at least one of the following components: (a) “Assistive technology consultation” means an evaluation of the assistive technology needs of an individual, including a functional evaluation of technologies available to address the individual’s assessed needs and support the individual to achieve outcomes identified in his or her individual service plan. (b) “Assistive technology equipment ” means the cost of leasing, purchasing, warranty at purchase, or otherwise providing for the acquisition of equipment and may include engineering, designing, fitting, customizing, or otherwise adapting the equipment to meet an individual’s specific needs. Assistive technology equipment may include Personal Emergency Response Systems (PERS), Mobile Emergency Response Systems (MERS), Medication Reminder Systems (MRS) and equipment such as motion sensing system, live video feed, or live audio feed. Assistive technology cannot be accessed to purchase video monitors or cameras to be placed in bedrooms and bathrooms. (c) “Assistive technology service delivery” means monthly implementation of service and monitoring of the technology equipment and individual as necessary. (d) “Assistive technology support” is intended for education and training beyond that included in initial installation/training and routine service delivery questions and implementation that aids an individual in the use of assistive technology equipment as well as training for the individual’s family members, guardians, staff, or other persons who provide natural supports or paid services, employ the individual, or who are otherwise substantially involved in activities being supported by the assistive technology equipment. Assistive technology support may include, when necessary, coordination with complementary therapies or interventions and adjustments to existing assistive technology to ensure its ongoing effectiveness.

Limits on the amount, duration, or frequency of this service:

Assistive technology equipment does not include items otherwise available as environmental accessibility

adaptations or specialized medical equipment and supplies.

Assistive technology consultation is limited to one per year. An exception may be extended if the participant is pursuing a new or additional type of technology in the same year.

Assistive technology support is limited to 40 hours per year.

The costs of all components of Assistive Technology equipment shall not exceed $9,000 per annual support plan year, per individual.

An individual cannot receive the Mobile Emergency Response Systems (MERS) and the Personal Emergency Response Systems (PERS) service at the same time.

The services under the Community Support Waiver are limited to additional services not otherwise covered under the state plan, including EPSDT. Children have access to any medically necessary preventive, diagnostic, and treatment services under Medicaid’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services to help meet children’s health and developmental needs. This includes age appropriate medical, dental, vision, and hearing screening services and diagnostic and treatment services to correct or ameliorate identified conditions.

Supports provided by this waiver service is to improve and maintain the ability of the child to remain in and engage in community activities.

When this service is provided to minor children living with their parents or guardians, it shall not supplant the cost and provision of support ordinarily provided by parents to children without disabilities, educationally related services and support that is the responsibility of local education authorities, nor shall it supplant services through EPSDT

If a person’s need can’t be met within a limit, attempts will be made to locate another funding source or an exception may be approved by the by the director or designee to exceed the limit if exceeding the limit will result in decreased need (units) of one or more other waiver services. The service plan must document exceeding the limit for the service that will result in a decreased need of one or more other waiver services. If it is determined the needs of a significant number of individuals cannot be met within the limitation, an amendment will be requested to increase the amount of the limitation.

Benefits Planning is a service designed to inform an individual about competitive integrated employment and assist them to assess if it will result in increased economic self-sufficiency and/or net financial benefit through the use of various work incentives. This service provides information to the participant regarding the full array of available work incentives for essential benefit programs including Supplemental Security Income, SSDI, Medicaid, Medicare, housing subsidies, food stamps, ABLE accounts, etc.

The service also will provide information, education, consultation and technical assistance to the individual regarding:

Income reporting requirements for public benefit programs, including the Social Security Administration

Formalized development of Plans for Achieving Self Sufficiency (PASS), Property Essential to Self-Support (PESS)

Assistance with utilization of social security work incentives

Coordination of Social Security and Medicaid work incentives and benefits support

Individual benefit verification, consultation, education and ongoing analysis/planning.

Benefits Planning can be provided to individuals considering or seeking competitive integrated employment, career advancement or to individuals who need financial problem solving assistance to maintain competitive integrated employment.

This service may be provided in person or virtually based on the individual’s informed choice.

Benefits Planning may only be provided if a Certified Work Incentives Counselor through a Missouri-based Social Security Supported Work Incentives Planning and Assistance (WIPA) program were sought and it is documented by the Supports Coordinator that such services were not available, accessible or applicable due to either ineligibility or because of wait lists that would result in services not being available within 30 calendar days (this is only required once per year; i.e., it must be repeated if Benefits Planning is needed in a subsequent year).

(PLEASE SEE MAIN SECTION B-OPTIONAL FOR THE ADDITIONAL INFORMATION ABOUT VIRTUAL DELIVERY OF SERVICE)

Limits on the amount, duration, or frequency of this service:

Benefits Planning services are limited to a maximum of 60units per annual support plan for any combination of initial benefits planning, supplementary benefits planning when an individual is evaluating a job offer/promotion or a self-employment opportunity, or problem-solving assistance to maintain competitive integrated employment. Additional units may be approved by the Division’s Regional Director or designee in exceptional circumstances.

Career Planning is a comprehensive individualized service which supports a participant with vocational discovery, identification of career themes (pathways) and development of a plan to achieve competitive integrated or self- employment goals. The outcome of this service is documentation of the individual’s stated career objective and a completed career plan/discovery profile used to guide ongoing individual employment support needs.

Career Planning activities may include but are not limited to the coordination and delivery of:

Home and neighborhood observations

Job exploration

Job shadowing

Informational interviewing

Work specific review of assistive technology

Assessment of interests and skills

Labor market research

Vocational and job related discovery on asset development

Providers of this service may coordinate, evaluate and communicate not only with the individual but, also with their caregivers, support team, employers, teachers and others who can assist with discovering an individual’s skills, abilities, interests, preferences, conditions and needs. This support and evaluation should be provided in the presence of the individual to the maximum extent possible and should be conducted in the community to the maximum extent possible; but, completion of activities in the home or without the presence of the individual is not precluded.

If an individual is employed, career planning may be used to explore other ongoing competitive employment career objectives which are consistent with the person’s skills and interests or explore advancement opportunities in his or her chosen career.

Career Planning should be reviewed and considered as a component of an individual’s person-centered services and supports plan no less than annually, more frequently as necessary or as requested by the individual. These services and supports should be designed to support successful employment outcomes consistent with the individual’s goals.

Career Planning furnished under the waiver may not include services available under a program funded under section 110 of the Rehabilitation Act of 1973 and its amendments or section 602(16) and (17) of the Individuals with Disabilities Education Act (20 U.S.C. 1401(16 and 17)). Therefore, the case record for any individual receiving this service must document the individual is not eligible for, unable to access, exhausted services or otherwise inapplicable for the aforementioned programs as outlined in an MOU between Vocational Rehabilitation and the Division of DD.

Transportation costs for the implementation of Career Planning services are included in the unit rate.

Assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) to participate in this service are considered incidental and included in this service.

Outcomes expected for this service are as follows:

An identified career path and profile which includes the individual’s needs, interests, strengths, natural supports and characteristics of potential work environments and a plan specifying actions necessary to achieve the individual’s career goals.

Service Documentation:

Providers of Career Planning must maintain an individualized plan and detailed record of activities by unit of service.

(PLEASE SEE MAIN SECTION B-OPTIONAL FOR THE ADDITIONAL INFORMATION ABOUT VIRTUAL DELIVERY OF SERVICE)

Limits on the amount, duration, or frequency of this service:

Career Planning is intended to be time-limited. Services should be authorized through person centered employment planning based upon individualized assessed need not to exceed 240 units of services within an annual support plan. Additional units may be approved by the Division’s Regional Director or designee in exceptional circumstances.

Community Networking, formerly known as Community Integration coordinates and provides support for valued and active participation in integrated activities that build on the person’s interests, preferences, gifts, and strengths while reflecting the person’s goals with regard to community involvement and membership. Community Networking services are designed to increase an individual’s connection to and engagement in formal and informal community supports. Services are designed to develop flexible, sustainable, and supportive community resources and relationships. Individuals are introduced to community resources and supports that are available in their area and supported to develop skills that will facilitate integration into their community. Outcomes for this service include positive relationships, valued community roles, and involvement in preferred community activities/organizations/groups/projects/other resources. Community Networking outcomes are developed through a person centered planning process and provided in accordance with the individual support plan. Expectations are for paid supports to be decreased and transitioned to natural supports over time when possible. Community Networking is not intended or designed to be used in employment settings. Personal Assistant services may be a component of Community Networking as necessary for the individual to participate in the service but may not comprise the entirety of the service. Transportation costs related to the provision of this service in the community are included in the service rate.

Limits on the amount, duration, or frequency of this service:

This service is limited to 432 units (108 hours per month). Individuals who receive Group Home, Individualized Supported Living, or Shared Living may not receive this service Group Community Networking may not exceed 4 individuals per staff person.

Individualized Skill Development (ISD) are individualized supports, delivered in a personalized manner, to support individuals who live in their own or family homes with acquiring, building, or maintaining complex skills necessary to maximize their personal independence. Teaching methods are individualized to what the participant wants to accomplish, learn and/or change based on the identified skill as developed in the person-centered planning process and provided in accordance with the individual support plan to achieve identified outcomes. Complex skills development include but is not limited to domestic and home maintenance, budgeting and money management, and using public transportation. Transportation costs related to the provision of this service in the community are included in the service rate. This is an episodic support of a clearly identified skill as developed through a person centered planning process and provided in accordance with the individual support plan the provider must document monthly progress toward achieving each skill identified in the individual support plan which shall include an annual review of progress towards the individual’s independent living goals. Personal Assistant services may be a component part of Individualized Skill Development as necessary for the individual to participate in the service but may not comprise the entirety of the service. The UR process, authorized under 9 CSR 45-2.017 ensures all services authorized are necessary based on the needs of the individual.

Limits on the amount, duration, or frequency of this service:

Individuals who receive Group Home, Individualized Supported Living, or Shared Living may not receive this service. The service is limited to 348 units (87 hours) a month. When this service is provided to minor children living with their parents or guardians, it shall not supplant the cost and provision of support ordinarily provided by parents to children without disabilities, educationally related services and support that is the responsibility of local education authorities, nor shall it supplant services through EPSDT This service may not be provided by a family member or guardian. Group Individualized Skill Development may not have more than 4 individuals in a group. This service is limited to additional services not otherwise covered under the state plan, including EPSDT, but consistent with waiver objectives of avoiding institutionalization.

Job Development is a support service to facilitate competitive work in an individual integrated work setting. The service must be identified in the individual’s service plan based upon an individualized assessed need which promotes the greatest degree of integration, independence and autonomy.

Job Development services are the supports to individuals who, because of the disabilities, will need assistance with obtaining individual competitive or customized employment in an integrated work setting in the general workforce at or above the state’s minimum wage, at or above the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities. The outcome of this service is the acceptance of an employment offer in a job that meets personal and career goals.

Job Development services may include:

Application completion assistance with the individual,

Job interviewing activities with the individual,

Completion of job analysis and/or task analysis with or without the presence of the individual based upon individualized need,

Negotiation with prospective employers and education of prospective employers of their role in promoting full inclusion with or without the presence of the individual based upon individualized need,

Consultation with the prospective employer on the use of assistive technology to promote greater autonomy and independence in the potential workplace,

Consultation and negotiation of work hours, wages and earnings.

Additional Information about Job Development services:

Job Development services must be provided in a manner that promotes integration into the workplace and interaction between individuals and people without disabilities in those workplaces while maintaining the individual’s rights of dignity, privacy and respect.

This service and support should be designed to support a successful employment outcome consistent with the individual’s assessed goals, needs, interests and preferences. An individual’s autonomy and independence to perform employment with the least amount of restrictions must be supported through the person centered planning process.

Job Development should be reviewed and considered as a component of an individual’s person-centered services and supports plan no less than annually, more frequently as necessary or as requested by the individual.

Job Development furnished under the waiver may not include services available under a program funded under section 110 of the Rehabilitation Act of 1973 and its amendments or section 602(16) and (17) of the Individuals with Disabilities Education Act (20 U.S.C. 1401(16 and 17)). Therefore, the case record for any individual receiving this service must document the individual is not eligible for, unable to access, exhausted services or otherwise inapplicable for the aforementioned programs as outlined in an interagency MOU between Vocational Rehabilitation and the Division of DD.

Assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) to participate in this service are considered incidental and included in this service.

Transportation costs are included in the implementation of the Job Development service.

FFP is not claimed for incentive payments, subsidies, or unrelated vocational training expenses such as the following:

Incentive payments made to an employer to encourage or subsidize the employer’s participation in a supported employment program; or

Payments that are passed through to users of community employment programs.

Outcomes expected for this service are as follows:

A job retention plan to include job title, wages, projected average number of hours to be worked weekly and recommended implementation strategies for paid/natural supports regarding unmet needs (i.e. personal assistance, transportation, skill acquisition, employment onboarding, workplace integration, etc.).

Service Documentation :

Providers of Job Development must maintain an individualized plan and detailed record of activities by unit of service.

(PLEASE SEE MAIN SECTION B-OPTIONAL FOR THE ADDITIONAL INFORMATION ABOUT VIRTUAL DELIVERY OF SERVICE)

Transportation services are also available under this waiver to support access to community activities as identified through the individual’s person-centered plan.

Personal Assistant Services include a range of assistance for any activities of daily living (ADL) or instrumental activity of daily living (IADL) to enable individuals to complete tasks they are not able to do for themselves due to their disability. This may take the form of hands on assistance (actually performing a task for the individual), cueing to the individual to perform a task, or performing the task for the individual if they are not able to do for themselves. Personal assistant services provide support and incidental teaching to assist the individual to participate fully in their home and community life. These supports can be provided in the participant’s own home, family home, and in the community, and always provided in the presence of the individual.

While Personal Assistant service is ordinarily provided on a one-to-one basis, personal assistance may be delivered to groups of individuals when it is determined to meet the individuals’ needs. With written approval from the Regional Office Director, personal assistant services may be delivered to groups of four (4) to six (6) persons when it is determined the needs of each individual in the group can be safely met.

Personal Assistant staff are required to be awake at all times. Personal Assistant Services may be provided on an episodic or continuing basis. Personal Assistant Services may be provided by an agency or as a self-directed option.

Relatives as Providers:

Relatives (parent, step-parent, foster parent, sibling, child (by blood, adoption, or marriage), spouse, grandparent, or grandchild) may be approved to provide personal assistant services through an agency or self-directed with exceptions listed below.

The following cannot be a provider of personal assistant services:

Individual’s spouse

Parent, step-parent, or foster parent of a minor child (under age 18)

The individual’s guardian

Self-directed supports designated representative or employer of record.

When a relative provides personal assistance, the ISP must reflect:

The individual is not opposed to the relative providing the services;

The planning team determines the paid relative providing the service best meets the individual’s needs;

The services to be provided are solely for the individual and not the benefit of the household/family unit;

A relative will only be paid for the hours authorized in the support plan and at no time can these exceed 40 hours per week. Any support provided above this amount would be considered a natural support or the unpaid care that a family member would typically provide.

Difference between State Plan Personal Care and DD waiver Personal Assistant Services

Personal Assistant Service under the waiver differs in scope, nature, supervision arrangements, limitation of amount, and/or provider type from personal care services in the State Plan.

Personal Assistant Services (PA) differ from State Plan in the following ways:

PA may be provided in the community.

PA must always be provided in the presence of the individual receiving the service.

PA can provide support with medication administration and management. (Personal Assistant, Medical, unless self-directed)

PA can provide specialized healthcare and medical tasks or tasks requiring nursing delegation (Personal Assistant, Medical, unless self-directed)

PA may be self-directed through the use of a designated representative

When an individual’s need for personal assistant service can be met through the MO HealthNet state plan personal care program administered by the Division of Senior and Disability Services (DSDS) with the Missouri Department of Health and Senior Services (DHSS), he or she will not be eligible for Personal Assistant Services under the waiver, in accordance with the requirement that state plan services must be exhausted before waiver services can be provided.

After State Plan Personal Services have been exhausted, DD Waiver personal assistant may be authorized when:

State plan limits on number of units for personal care are reached and more assistance with ADLs and/or IADLs is needed;

The individual has medical needs and they require a more highly trained personal assistant than is available under state plan;

When the personal assistant worker is related to the individual; or

When the individual or family is directing the service through the Vendor Fiscal Employer Agent (VF/EA) Financial Management Services (FMS) contractor.

When waiver personal assistant is authorized to adults also eligible for state plan personal care, the Support coordinator must consult and coordinate the waiver support plan with the DSDS service authorization system. Personal care services are provided to children with disabilities according to the federal mandates of the Early Periodic Screening, Diagnosis and Treatment (EPSDT) program. Personal Assistant needs for the eligible individual through EPSDT, as applicable, shall be accessed and utilized, in accordance with the requirement that state plan services must be exhausted before waiver services can be provided. Personal Assistant services authorized through the waiver shall not duplicate state plan personal care services. State plan personal care services for children are coordinated through the Bureau of Special Health Care Needs (BSHCN) through DHSS.

When waiver personal assistant is authorized for children also eligible for state plan personal care, the Support Coordinator must consult and coordinate with the BSHCN service authorization system.

Personal Assistant, Self-Directed option

Self-Directed Supports is an option of service delivery for individuals who wish to exercise more choice, control and authority over their supports.

Team Collaboration, Self-directed option

Team collaboration is available under Self-Directed Services only. Team collaboration allows the individual’s employees to participate in the Individual Support Plan and to meet as a team to ensure consistency in its implementation. A team meeting also can be convened by the individual or their designated representative for the purposes of discussing specific needs of the individual, the individualized progress towards outcomes, and other related concerns. Team collaboration can be included in the individual budget limited to 120 hours per plan year. Team collaboration is included in the rate for agency-based personal assistant services.

Personal Assistant, Medical option (Agency or Self-directed)

To assist in meeting the specialized medical needs for the individual as identified by the team and documented in the ISP, the following must have been met:

The interdisciplinary team has identified and outlined the need to pursue more intensive support for medically related issues;

The need must be documented by a physician or advanced practice nurse and maintained on file;

Prior to approval of funding for medical personal assistance the ISP has gone through the local UR review process to determine the above have been completed.

Depending upon the scope of services, a registered professional nurse may be required to provide oversight in accordance with the Missouri Nurse Practice Act.

For individuals hospitalized, personal assistant services may be provided to assist with supports, supervision, communication, and any other supports that the hospital is unable to provide. The service will: be identified in an individual’s person-centered service plan; provided to meet needs of the individual that are not met through the provision of hospital services; not substitute for services that the hospital is obligated to provide through its conditions of participation or under Federal or State law, or under another applicable requirement; and be designed to ensure smooth transitions between acute care settings and home and community-based settings, and to preserve the individual’s functional abilities.

For individuals hospitalized, personal assistant services may be provided to assist with supports, supervision, communication, and any other supports that the hospital is unable to provide. The service will: be identified in an individual’s person-centered service plan; provided to meet needs of the individual that are not met through the provision of hospital services; not substitute for services that the hospital is obligated to provide through its conditions of participation or under Federal or State law, or under another applicable requirement; and be designed to ensure smooth transitions between acute care settings and home and community-based settings, and to preserve the individual’s functional abilities.

Limits on the amount, duration, or frequency of this service:

Individuals who receive Group Home, Individualized Supported Living, or Shared Living may not receive this service. When this service is provided to minor children living with their parents or guardians, it shall not supplant the cost and provision of support ordinarily provided by parents to children without disabilities, educationally related services and support that is the responsibility of local education authorities, nor shall it supplant personal care through EPSDT. Personal Services through EPSDT for eligible persons under age 21 shall be provided and utilized first before the waiver Personal Assistant Service is provided. Children have access to EPSDT services. Children have access to any medically necessary preventive, diagnostic, and treatment services under Medicaid’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services to help meet children’s health and developmental needs. This includes age appropriate medical, dental, vision, and hearing screening services and diagnostic and treatment services to correct or ameliorate identified conditions. Supports provided by this waiver service is to improve and maintain the ability of the child to remain in and engage in community activities. The services are limited to additional services not otherwise covered under the state plan, including EPSDT, but consistent with waiver objectives of avoiding institutionalization.

Prevocational Services provide one-to-one learning and group experiences to further develop an individual’s general, non-job-task-specific skills needed to succeed in competitive, integrated employment (work settings where compensation is at or above minimum wage). Services are expected to occur over a defined period of time with specific and measurable outcomes to be achieved. Services prepare the individual to attain the highest level of independence and autonomy in the most integrated employment setting aligned with the individual’s interests, abilities, and capabilities.

Prevocational services includes activities that are primarily directed at assisting an individual with developing non- job task specific skills that are associated with performing competitive work in community integrated employment. Providers of this service may coordinate, evaluate and communicate not only with the individual but, also with community businesses to develop unpaid work experiences. This service should be provided in the presence of the individual to the maximum extent possible and should be conducted in the community to the maximum extent possible but completion of activities without the presence of the individual should not be precluded.

Prevocational services may include volunteering, uncompensated work experience and compensated work experience settings to support the development of expanded habilitation skills. Any limitations on location or duration of these experiences are established and governed through the US Department of Labor (DOL) Fair Labor Standards Act and Wage and Hour Laws. It is the service provider’s responsibility to understand these industry specific term and act in accordance to DOL regulations.

Services may be provided in a community setting or at a certified or accredited facility of a qualified employment service provider. The setting for the delivery of services must be aligned with the individualized assessed need and that which is most conducive in developing the specific and measurable outcomes contained within the Individual Support Plan. Services cannot be provided within an individual’s residence.

Services are intended to develop and teach expanded habilitative skills that lead to competitive and integrated employment including, but not limited to:

Communication with supervisors, co-workers and customers

Work appropriate conduct, hygiene and dress

Workplace problem solving skills

Use of strategies, to include assistive technology, for task attendance and completion

Workplace safety skills

Mobility and motor skills training

Asset development and financial literacy

Vocational services, which are not covered through home and community-based waivers, are job task specific skills training required by a participant for the primary purpose of completing those tasks for a specific facility-based job or those delivered in a segregated setting. The distinction between vocational and pre-vocational services is that Prevocational Services are delivered for the purpose of furthering habilitation goals that will lead to greater opportunities for competitive integrated employment or further career advancement.

Participation in Prevocational Services is not a pre-requisite for supported employment services. Prevocational Services should only be authorized when an individual is otherwise unable to directly enter the general workforce as a result of an underdeveloped or undeveloped general, non-job-task-specific skill(s).

Prevocational Services can be provided in small groups not exceeding four (4) individuals at a time. The decision to provide services in a group setting must be based on individualized assessed need and be supported in the person-centered plan as being the most autonomous setting which facilitates the highest levels of individual learning.

The provision of Prevocational Services is always delivered with the intention of developing skills which will lead to competitive integrated employment. Volunteering for personal reasons not related to future employment would not be Prevocational Services.

All Prevocational Services should be reviewed and considered as a component of an individual’s person-centered services and supports plan no less than annually, more frequently as necessary or as requested by the individual. These services and supports should be designed to support successful employment outcomes consistent with the individual’s goals.

Personal Assistant services may be a component of Prevocational service as necessary for the individual to

participate in the service but may not comprise the entirety of the service.

Transportation costs for the implementation of Prevocational Services are included in the unit rate .

Prevocational Services furnished under the waiver may not include services available under a program funded under section 110 of the Rehabilitation Act of 1973 and its amendments or section 602(16) and (17) of the Individuals with Disabilities Education Act (20 U.S.C. 1401(16 and 17)). Therefore, the case record for any individual receiving this service must document the individual is not eligible for, unable to access, exhausted services or otherwise inapplicable for the aforementioned programs as outlined in an interagency MOU between Vocational Rehabilitation and the Division of DD.

Prevocational services must comply with 42 CFR §440.180(c) (2) (i).

Outcomes expected for this service are as follows:

Monthly plan describing the progress on skill acquisition and ongoing development needed to be prepared for employment.

Service Documentation:

Providers of Prevocational Services must maintain an individualized plan and detailed record of activities by unit of service.

(PLEASE SEE MAIN SECTION B-OPTIONAL FOR THE ADDITIONAL INFORMATION ABOUT VIRTUAL DELIVERY OF SERVICE)

Limits on the amount, duration, or frequency of this service:

Must be authorized based upon individual need not to exceed 2,080 units per annual support plan year. Additional units may be approved by the Division’s Regional Director or designee in exceptional circumstances.

Supported employment is a support service to facilitate competitive work in an integrated work setting. The service must be identified in the individual’s service plan based upon an individualized assessed need which promotes the greatest degree of integration, independence and autonomy. Models of supported employment may include individual support or group support such as community business-based work groups and or mobile crews.

Individual and group services are defined separately below.

For those individuals whose individualized assessed need supports self-employment, Supported Employment Individual employment supports may include services and supports that assist the individual in achieving self- employment through the operation of a business; however, Medicaid funds may not be used to defray the expenses associated with starting up or operating a business. Assistance for self-employment may include ongoing assistance, counseling and guidance once the business has been launched.

Assistance for self-employment may include:

Aide to the individual in identifying potential business opportunities;

Assistance in the development of a business plan, including potential sources of business financing and other assistance in developing and launching a business; and

Identification of the supports that are necessary for the individual to operate the business.

Supported Employment- Individual Supported Employment

Individual Supported Employment services are the ongoing supports to individuals and their employers who, because of their disabilities, need intensive on-going support to maintain a job in competitive or customized employment, or self-employment, in an integrated work setting in the general workforce at or above the state’s minimum wage, at or above the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities. The outcome of this service is sustained paid employment at or above the minimum wage in an integrated setting in the general workforce, in a job that meets personal and career goals.

Supported Employment – Individual Supported Employment services may include:

On-the-job training in work and work-related skills; i.e. job coaching to facilitate the acquisition, and ongoing performance, of the essential functions of the job and the facilitation of natural supports (i.e. fading).

Ongoing retention, supervision and monitoring of the person’s performance; i.e. evaluating self-maintenance strategies, work production and the effectiveness of natural supports (i.e. fading) which promote the greatest degree of inclusion, integration and autonomy.

Training in related skills needed to retain employment; i.e. supporting and facilitating strategies which promote inclusion in the workplace based upon individualized assessed need such as using assistive devices, community resources and public transportation. This service should be provided in the presence of the individual to the maximum extent possible but completion of activities without the presence of the individual should not be precluded.

Supported Employment -Small Group Employment Support:

Group supported employment are services and training activities provided in regular community business and industry settings for groups of two (2) to four (4) workers with disabilities. Small group employment support does not include services provided in facility-based work settings or non-integrated work settings (i.e. settings which physically and socially isolate individuals from other employees). Examples include mobile crews and other community business-based workgroups employing small groups of workers with disabilities in integrated competitive employment in the community. The outcome of this service is sustained paid employment, work experience leading to further career development and individual integrated community-based employment for which an individual is compensated at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities. An annual review must occur to determine if the employment setting optimizes, but does not regiment, individual initiative, autonomy and independence in making employment choices.

Supported Employment – Small Group Employment Supports may include:

On-the-job training in work and work-related skills; i.e. job coaching to facilitate the acquisition, and ongoing performance, of the essential functions of the job and the facilitation of natural supports (i.e. fading).

Ongoing supervision and monitoring of the person’s performance on the job; i.e. evaluating self-maintenance strategies, work production and the effectiveness of natural supports (i.e. fading) which promote the greatest degree of inclusion, integration and autonomy.

Training in related skills needed to retain individual integrated community-based employment; i.e. supporting and facilitating strategies which promote attendance and social inclusion in the workplace based upon individualized assessed need such as using community resources and public transportation.

Additional Information about Supported Employment services:

Supported employment services must be provided in a manner that promotes integration into the workplace and interaction between individuals and people without disabilities in those workplaces while maintaining the individual’s rights of dignity, privacy and respect.

All Supported Employment service options should be reviewed and considered as a component of an individual’s person-centered services and supports plan no less than annually, more frequently as necessary or as requested by the individual. These services and supports should be designed to support successful employment outcomes consistent with the individual’s assessed goals, needs, interests and preferences. Supported Employment Group is not appropriate for individuals who demonstrate the capacity, ability and interest to work independently. An individual’s autonomy and independence to perform employment with the least amount of restrictions must be supported through the person centered planning process.

Supported Employment supports do not include payment for supervision, training, support and adaptations typically available to other workers without disabilities filling similar positions in the business or otherwise covered under the Americans with Disabilities Act.

Supported Employment may include assistance with reporting and managing earnings with Social Security and Medicaid.

However, Personal Assistance Service may not be used in lieu of Supported Employment services as defined above.

Personal Assistant services may be a component of Supported employment as necessary for the individual to participate in the service but may not comprise the entirety of the service.

Transportation costs are not included in the supported employment rate . Transportation is available as a separate service if necessary and able to be coordinated through the person centered planning team. Supported Employment furnished under the waiver may not include services available under a program funded under section 110 of the Rehabilitation Act of 1973 and its amendments or section 602(16) and (17) of the Individuals with Disabilities Education Act (20 U.S.C. 1401(16 and 17)). Therefore, the case record for any individual receiving this service must document the individual is not eligible for, unable to access, exhausted services or otherwise inapplicable for the aforementioned programs as outlined in an interagency memorandum of understanding between Vocational Rehabilitation and the Division of Developmental Disabilities.

Federal Financial Participation (FFP) is not claimed for incentive payments, subsidies, or unrelated vocational training expenses such as the following:

Incentive payments made to an employer to encourage or subsidize the employer’s participation in a supported employment program; or

Payments that are passed through to users of supported employment programs.

Outcomes expected for this service are as follows:

Monthly retention plan describing the results of the professional observation and assessment of the individual and their current and needed paid/unpaid supports to sustain employment. The retention plan includes a summary of implementation strategies to maximize employment, independence, natural supports, job performance and addressing any identified potential risk associated with reduction of paid supports.

Service Documentation:

Providers of Supported Employment must maintain an individualized plan and detailed record of monthly activities by unit of service.

(PLEASE SEE MAIN SECTION B-OPTIONAL FOR THE ADDITIONAL INFORMATION ABOUT VIRTUAL DELIVERY OF SERVICE)

Limits on the amount, duration, or frequency of this service:

N/A

“Assistive technology” means a device, product system, or engineered solution whether acquired commercially, modified, or customized that addresses an individual’s needs and outcomes identified in his or her individual service plan. The service is for the direct benefit of the individual in maintaining or improving independence, functional capabilities, vocational skills, or community involvement. The individual’s person-centered planning team will ensure that the individual understands the use of technology, the individual/family has information needed in order to make an informed choice/consent and that he/she understands privacy protections as documented in the approved ISP. The Support Coordinator and providers will share responsibility for monitoring privacy concerns. The ISP documents all back-up support plans based on the individual’s needs. The ISP will document who is responsible for the monitoring activity and if they are on-site or off-site. Assistive technology must include at least one of the following components : (a) “Assistive technology consultation” means an evaluation of the assistive technology needs of an individual, including a functional evaluation of technologies available to address the individual’s assessed needs and support the individual to achieve outcomes identified in his or her individual service plan. (b) “Assistive technology equipment ” means the cost of leasing, purchasing, warranty at purchase or otherwise providing for the acquisition of equipment and may include engineering, designing, fitting, customizing, or otherwise adapting the equipment to meet an individual’s specific needs. Assistive technology equipment may include Personal Emergency Response Systems (PERS), Mobile Emergency Response Systems (MERS), Medication Reminder Systems (MRS) and equipment such as motion sensing system, live video feed, or live audio feed. Assistive technology cannot be accessed to purchase video monitors or cameras to be placed in bedrooms and bathrooms. (c)“Assistive technology service delivery” means monthly implementation of service and monitoring of the technology equipment and individual as necessary. (d)“Assistive technology support” is intended for education and training beyond that included in initial installation/training and routine service delivery questions and implementation that aids an individual in the use of assistive technology equipment as well as training for the individual’s family members, guardians, staff, or other persons who provide natural supports or paid services, employ the individual, or who are otherwise substantially involved in activities being supported by the assistive technology equipment. Assistive technology support may include, when necessary, coordination with complementary therapies or interventions and adjustments to existing assistive technology to ensure its ongoing effectiveness.

Limits on the amount, duration, or frequency of this service:

Assistive technology equipment does not include items otherwise available as environmental accessibility adaptations or specialized medical equipment and supplies.

Assistive technology consultation is limited to one per year. An exception may be extended if the participant is pursuing a new or additional type of technology in the same year.

Assistive technology support is limited to 40 hours per year.

The costs of all components of Assistive Technology equipment shall not exceed $9,000 per annual support plan year, per individual.

An individual cannot receive the Mobile Emergency Response Systems (MERS) and the Personal Emergency Response Systems (PERS) service at the same time.

The services under the PFH Waiver are limited to additional services not otherwise covered under the state plan, including EPSDT.

Children have access to any medically necessary preventive, diagnostic, and treatment services under Medicaid’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services to help meet children’s health and developmental needs. This includes age appropriate medical, dental, vision, and hearing screening services and diagnostic and treatment services to correct or ameliorate identified conditions. Supports provided by this waiver service is to improve and maintain the ability of the child to remain in and engage in community activities.

When this service is provided to minor children living with their parents or guardians, it shall not supplant the cost and provision of support ordinarily provided by parents to children without disabilities, educationally related services and support that is the responsibility of local education authorities, nor shall it supplant services through EPSDT.

If a person’s need can’t be met within a limit, attempts will be made to locate another funding source or an exception may be approved by the director or designee to exceed the limit if exceeding the limit will result in decreased need (units) of one or more other waiver services. The service plan must document exceeding the limit for the service that will result in a decreased need of one or more other waiver services . If it is determined the needs of a significant number of individuals cannot be met within the limitation, an amendment will be requested to increase the amount

of the limitation.

Benefits Planning is a service designed to inform an individual about competitive integrated employment and assist them to assess if it will result in increased economic self-sufficiency and/or net financial benefit through the use of various work incentives. This service provides information to the participant regarding the full array of available work incentives for essential benefit programs including Supplemental Security Income, SSDI, Medicaid, Medicare, housing subsidies, food stamps, ABLE accounts, etc.

The service also will provide information, education, consultation and technical assistance to the individual regarding:

Income reporting requirements for public benefit programs, including the Social Security Administration

Formalized development of Plans for Achieving Self Sufficiency (PASS), Property Essential to Self-Support (PESS)

Assistance with utilization of social security work incentives

Coordination of Social Security and Medicaid work incentives and benefits support

Individual benefit verification, consultation, education and ongoing analysis/planning.

Benefits Planning can be provided to individuals considering or seeking competitive integrated employment, career advancement or to individuals who need financial problem-solving assistance to maintain competitive integrated employment.

This service may include activity on behalf of the individual to assist in provision of the benefits planning service. The service can be provided in person or virtually based on the individual’s informed choice.

Benefits Planning may only be provided if a Certified Work Incentives Counselor through a Missouri-based Social Security Supported Work Incentives Planning and Assistance (WIPA) program were sought and it is documented by the Support Coordinator that such services were not available, accessible or applicable due to either ineligibility or because of wait lists that would result in services not being available within 30 calendar days (this is only required once per year; i.e., it must be repeated if Benefits Planning is needed in a subsequent year).

(PLEASE SEE MAIN SECTION B-OPTIONAL FOR THE ADDITIONAL INFORMATION ABOUT VIRTUAL DELIVERY OF SERVICE)

Limits on the amount, duration, or frequency of this service:

Benefits Planning services are limited to a maximum of 60 units per annual support plan for any combination of initial benefits planning, supplementary benefits planning when an individual is evaluating a job offer/promotion or a self-employment opportunity, or problem-solving assistance to maintain competitive integrated employment. Additional units may be approved by the Division’s Regional Director or designee in exceptional circumstances.

Career Planning is a comprehensive individualized service which supports a participant with vocational discovery, identification of career themes (pathways) and development of a plan to achieve competitive integrated or self- employment goals. The outcome of this service is documentation of the participant’s stated career objective and a completed career plan/discovery profile used to guide ongoing individual employment support needs.

Career Planning activities may include but are not limited to the coordination and delivery of:

Home and neighborhood observations

Job exploration

Job shadowing

Informational interviewing

Work specific review of assistive technology

Assessment of interests and skills

Labor market research

Vocational and job related discovery on asset development

Providers of this service may coordinate, evaluate and communicate not only with the individual but, also with their caregivers, support team, employers, teachers and others who can assist with discovering an individual’s skills, abilities, interests, preferences, conditions and needs. This support and evaluation should be provided in the presence of the individual to the maximum extent possible and should be conducted in the community to the maximum extent possible; but, completion of activities in the home or without the presence of the individual is not precluded.

If an individual is employed, career planning may be used to explore other ongoing competitive employment career objectives which are consistent with the person’s skills and interests or explore advancement opportunities in his or her chosen career.

Career Planning should be reviewed and considered as a component of an individual’s person-centered services and supports plan no less than annually, more frequently as necessary or as requested by the individual. These services and supports should be designed to support successful employment outcomes consistent with the individual’s goals.

Career Planning furnished under the waiver may not include services available under a program funded under section 110 of the Rehabilitation Act of 1973 and its amendments or section 602(16) and (17) of the Individuals with Disabilities Education Act (20 U.S.C. 1401(16 and 17)). Therefore, the case record for any individual receiving this service must document the individual is not eligible for, unable to access, exhausted services or otherwise inapplicable for the aforementioned programs as outlined in an interagency MOU between Vocational Rehabilitation and the Division of DD.

Transportation costs for the implementation of Career Planning services are included in the unit rate.

Personal care assistance may be provided to support an individual while receiving this service, but may not comprise the entirety of the service.

Outcomes expected for this service are as follows:

An identified career path and profile which includes the individual’s needs, interests, strengths, natural supports and characteristics of potential work environments and a plan specifying actions necessary to achieve the individual’s career goals.

Service Documentation:

Providers of Career Planning must maintain an individualized plan and detailed record of activities by unit of service.

(PLEASE SEE MAIN SECTION B-OPTIONAL FOR THE ADDITIONAL INFORMATION ABOUT VIRTUAL DELIVERY OF SERVICE)

Limits on the amount, duration, or frequency of this service:

Career Planning is intended to be time-limited. Services should be authorized through person centered employment planning based upon individualized assessed need not to exceed 240 units of services within annual support plan. Additional units may be approved by the Division’s Regional Director or designee in exceptional circumstances.

Community Networking, formerly known as Community Integration coordinates and provides support for valued and active participation in integrated activities that build on the person’s interests, preferences, gifts, and strengths while reflecting the person’s goals with regard to community involvement and membership. Community Networking services are designed to increase an individual’s connection to and engagement in formal and informal community supports. Services are designed to develop flexible, sustainable, and supportive community resources and relationships. Individuals are introduced to community resources and supports that are available in their area and supported to develop skills that will facilitate integration into their community. Outcomes for this service include positive relationships, valued community roles, and involvement in preferred community activities/organizations/groups/projects/other resources. Community Networking outcomes are developed through a person centered planning process and provided in accordance with the individual support plan. Expectations are for paid supports to be decreased and transitioned to natural supports over time when possible. Community Networking is not intended or designed to be used in employment settings. Personal Assistant services may be a component of Community Networking as necessary for the individual to participate in the service but may not comprise the entirety of the service. Transportation costs related to the provision of this service in the community are included in the service rate.

Limits on the amount, duration, or frequency of this service:

This service is limited to 432 units (108 hours) per month. Individuals who receive Group Home, Individualized Supported Living, or Shared Living may not receive this service. Group Community Networking may not exceed 4 individuals per staff person.

Individualized Skill Development (ISD) are individualized supports, delivered in a personalized manner, to support individuals who live in their own or family homes with acquiring, building, or maintaining complex skills necessary to maximize their personal independence. Teaching methods are individualized to what the participant wants to accomplish, learn and/or change based on the identified skill as developed in the person-centered planning process and provided in accordance with the individual support plan to achieve identified outcomes. Complex skills development include but is not limited to domestic and home maintenance, budgeting and money management, and using public transportation. Transportation costs related to the provision of this service in the community are included in the service rate. This is an episodic support of a clearly identified skill as developed through a person centered planning process and provided in accordance with the individual support plan the provider must document monthly progress toward achieving each skill identified in the individual support plan which shall include an annual review of progress towards the individual’s independent living goals. Personal Assistant services may be a component of Individualized Skill Development as necessary for the individual to participate in the service but may not comprise the entirety of the service. The UR process, authorized under 9 CSR 45-2.017 ensures all services authorized are necessary based on the needs of the individual.

Limits on the amount, duration, or frequency of this service:

Individuals who receive Group Home, Individualized Supported Living, or Shared Living may not receive this service This service is limited to 348 units (87 hours) a month. When this service is provided to minor children living with their parents or guardians, it shall not supplant the cost and provision of support ordinarily provided by parents to children without disabilities, educationally related services and support that is the responsibility of local education authorities, nor shall it supplant services through EPSDT. This service may not be provided by a family member or guardian. Group Individualized Skill Development may not have more than 4 individuals in a group. This service is limited to additional services not otherwise covered under the state plan, including EPSDT, but consistent with waiver objectives of avoiding institutionalization.

Job Development is a support service to facilitate competitive work in an individual integrated work setting. The service must be identified in the individual’s service plan based upon an individualized assessed need which promotes the greatest degree of integration, independence and autonomy.

Job Development services are the supports to individuals who, because of the disabilities, will need assistance with obtaining individual competitive or customized employment in an integrated work setting in the general workforce at or above the state’s minimum wage, at or above the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities. The outcome of this service is the acceptance of an employment offer in a job that meets personal and career goals.

Job Development services may include:

Application completion assistance with the individual,

Job interviewing activities with the individual,

Completion of job analysis and/or task analysis with or without the presence of the individual based upon individualized need,

Negotiation with prospective employers and education of prospective employers of their role in promoting full inclusion with or without the presence of the individual based upon individualized need.

Consultation with the prospective employer on the use of assistive technology to promote greater autonomy and independence in the potential workplace,

Consultation and negotiation of work hours, wages and earnings.

Additional Information about Job Development services:

Job Development services must be provided in a manner that promotes integration into the workplace and interaction between individuals and people without disabilities in those workplaces while maintaining the individual’s rights of dignity, privacy and respect.

This service and support should be designed to support a successful employment outcome consistent with the individual’s assessed goals, needs, interests and preferences. An individual’s autonomy and independence to perform employment with the least amount of restrictions must be supported through the person centered planning process.

Job Development should be reviewed and considered as a component of an individual’s person-centered services and supports plan no less than annually, more frequently as necessary or as requested by the individual.

Job Development furnished under the waiver may not include services available under a program funded under section 110 of the Rehabilitation Act of 1973 and its amendments or section 602(16) and (17) of the Individuals with Disabilities Education Act (20 U.S.C. 1401(16 and 17)). Therefore, the case record for any individual receiving this service must document the individual is not eligible for, unable to access, exhausted services or otherwise inapplicable for the aforementioned programs as outlined in an interagency MOU between Vocational Rehabilitation and the Division of DD.

Personal care assistance may be provided to support an individual while receiving this service, but may not comprise the entirety of the service.

Transportation costs are included in the implementation of Job Development service.

FFP is not claimed for incentive payments, subsidies, or unrelated vocational training expenses such as the following:

Incentive payments made to an employer to encourage or subsidize the employer’s participation in a supported employment program; or

Payments that are passed through to users of community employment programs.

Outcomes expected for this service are as follows:

A job retention plan to include job title, wages, projected average number of hours to be worked weekly and recommended implementation strategies for paid/natural supports regarding unmet needs (i.e. personal assistance, transportation, skill acquisition, employment onboarding, workplace integration, etc.).

Service Documentation:

Providers of Job Development must maintain an individualized plan and detailed record of activities by unit of service.

(PLEASE SEE MAIN SECTION B-OPTIONAL FOR THE ADDITIONAL INFORMATION ABOUT VIRTUAL DELIVERY OF SERVICE)

Limits on the amount, duration, or frequency of this service:

Job Development is intended to be time-limited. Services should be authorized through person centered employment planning based upon individualized assessed need not to exceed 240 units of services within an annual support plan. Additional units may be approved by the Division’s Regional Director or designee in exceptional circumstances.

Transportation services are also available under this waiver to support access to community activities as identified through the individual’s person-centered plan.

Excerpt from State Demonstration Application:

DBH recognizes the tremendous therapeutic value of employment for working-age individuals with behavioral health disorders and is committed to enhancing employment options for those individuals. Supported Employment is an evidence-based practice (EBP) that provides individualized services and supports to an individual to find competitive employment to promote stable employment. DBH works with the Department of Elementary and Secondary Education (DESE), Vocational Rehabilitation (VR) who provides job counseling, job-seeking skills, job placement, and vocational training to provide integrated services in the community behavioral health programs. The DBH provides ongoing benefits planning training for community provider staff and a web-based tool “Disability Benefits 101”. DBH has 31 community behavioral health locations designated as VR funded Community Rehabilitation Programs to provide evidence based supported employment services. DBH provides support services for mental health clients who are not currently eligible or ready for services from VR. MO HealthNet and DBH staff developed guidance documents on appropriate community support interventions reimbursable under the CPR and CSTAR treatment programs for consumers pursuing employment (DMH, 2012).

DBH has partnership with VR to implement IPS with 33 sites across 19 agencies.

Service Description

Community Support consists of specific activities with or on behalf of a person in accordance with an individualized treatment plan. Services are provided to maximize an individual’s immediate and continued community functioning while achieving and sustaining recovery/resiliency from mental illness and/or substance use disorders. These services are delivered in an amount and scope defined by each individual’s plan, and not all plans will contain all services.

Community support services for both adults and children focus on helping individuals develop skills, access resources and learn to manage illness in order to be successful in the living, working, learning, and social environments of their choice. Community Support staff teach, model, and practice skills with persons served in order to increase self-sufficiency and independence. The specific skills and supports are addressed on an individualized treatment plan (ITP) and based on the life domains that the person has identified as being impacted directly or indirectly by their serious mental illness, or substance abuse, or both. Community support services are time-limited based on recipient need, and rehabilitative in nature.

Community Support for children and youth is designed to coordinate and provide services and resources to children, adolescents and their families as necessary to promote resiliency. The focus is on teaching/modeling developmentally appropriate skills, necessary for positive self esteem, a sense of identity, positive relationships with family and peers, social competence, and success in school. The specific skills and supports are addressed on an individualized treatment plan (ITP) and based on the life domains that the child/family have identified as being impacted directly or indirectly by their serious emotional disturbance, or substance abuse, or both. A key in promoting resiliency is building on the strengths of the child’s natural support system which is also a key element of the ITP.

Community Support Key Service Functions

Providing holistic, person-centered care with emphasis on personal strengths, skill acquisition and harm reduction, while using stage-wise and motivational approaches that promote active participation by the individual in decision making and self-advocacy in all aspects of services and recovery/resiliency.

Using interventions, based on individual strengths and needs, to develop interpersonal/social, family, community and independent living functional skills including adaptation to home, school, family and work environments when the natural acquisition of those skills is negatively impacted by the individual’s mental illness and /or substance use disorder.

Facilitating and supporting recovery/resiliency through activities including: defining recovery/resiliency concepts in order to develop and attain recovery/resiliency goals; identifying needs, strengths, skills, resources and supports and teaching how to use them; and identifying barriers to recovery/resiliency and finding ways to overcome them.

Developing, implementing, updating, and revising as needed, a treatment plan that identifies specific, measurable and individualized interventions to reduce and manage symptoms, improve functioning and develop stability and independence. This plan is developed by a team consisting of the following as appropriate: the individual, family, community support specialist, community support supervisor, therapist, medication providers, schools, child welfare, courts and other supports.

Providing services that result in positive outcomes including but not limited to the following areas: employment/education, housing, social connectedness, abstinence/harm reduction, decreased criminality/legal involvement, family involvement, decreased psychiatric hospitalizations, and improved physical health.

Working collaboratively with the individual on treatment goals and service including the use of collaborative documentation as a tool to ensure that individuals are active in their treatment.

Documenting services that clearly describes the need for the service, the intervention provided, the relationship to the treatment plan, the provider of the service, the date, actual time and setting of the service, and the individual’s response to the service.

Developing a discharge and aftercare/continuing recovery plan to include, if applicable, securing a successful transition to continued services.

Contacting individuals and/or referral sources following missed appointments in order to re- engage and promote recovery/resiliency efforts.

Supporting individuals in crisis situations including locating and coordinating resources to resolve a crisis.

Maintaining contact with individuals who are hospitalized for medical or psychiatric reasons and participate in and facilitate discharge planning for psychiatric hospitalization and for medical hospitalization as appropriate.

Provide information and education in order to learn about and manage mental illness/serious emotional disturbance and/or substance use disorders including symptoms, triggers, cravings and use of medications.

Reinforce the importance of taking medications as prescribed and assist the individual to make medication concerns regarding side effects or lack of efficacy known to the prescriber.

Building skills for effective illness self-management including psychoeducation, behavioral tailoring for medication adherence, wellness/recovery planning, coping skills training, and social skills training.

In conjunction with the individual, family, significant others and referral sources, identifying risk factors related to relapse in mental illness and/or substance use disorders and develop a plan with strategies to support recovery and prevent relapse.

Make efforts to ensure that individuals gain and maintain access to necessary rehabilitative services, general entitlement benefits, employment, housing, schools, legal services, wellness or other services by actively assisting individuals to apply and follow-up on applications; and to gain skills in independently accessing needed services.

Ensuring communication and coordination with and between other interested parties such as service providers, medical professionals, referral sources, employers, schools, child welfare, courts, probation/parole, landlords, and natural supports.

Ensuring follow through with recommended medical care, to include scheduling appointments, finding financial resources and arranging transportation when individuals are unable to perform these tasks independently.

Developing and supporting wellness and recovery goals in collaboration with the individual, family and/or medical professionals, including healthy lifestyle changes such as healthy eating, physical activity and tobacco prevention and cessation; and coordination and monitoring of physical health and chronic disease management.

Assisting to develop natural supports including identification of existing and new natural supports in relevant life domains.

In coordination with the treatment team, improving skills in communication, interpersonal relationships, problem solving, conflict resolution; stress management; and identifying risky social situations and triggers that could jeopardize recovery.

Providing family education, training and support to develop the family as a positive support system to the individual. Such activities must be directed toward the primary well-being and benefit of the individual.

Helping individuals develop skills and resources to address symptoms that interfere with seeking or successfully maintaining a job, including but not limited to, communication, personal hygiene and dress, time management, capacity to follow directions, planning transportation, managing symptoms/cravings, learning appropriate work habits, and identifying behaviors that interfere with work performance.

Building skills associated with obtaining and maintaining success in school such as communication with teachers, personal hygiene and dress, age appropriate time management, capacity to follow directions and carry out school assignments, appropriate study habits, and identification of behaviors that interfere with school performance.

Building personal self care and home management skills associated with achieving and maintaining housing in the least restrictive setting by addressing issues like nutrition, meal preparation; household maintenance including house cleaning and laundry; money management and budgeting; personal hygiene and grooming; identification and use of social and recreational skills; use of available transportation; and personal responsibility.