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Supported Employment

Provider Requirements and Service Limitations

From The July 2007 Florida Medicaid Provider Handbook

Supported Employment- Requirements To Receive

Description

Supported employment services provide training and assistance in a variety of
activities to support recipients in sustaining paid employment at or above
minimum wage unless the recipient is operating a small business. The
supported employment provider assists with the acquisition, retention or
improvement of skills related to accessing and maintaining such employment
or developing and operating a small business. With the assistance of the
supported employment provider, the recipient is assisted in securing
employment according to their desired outcomes, including the type of work
environment, activities, hours of work, level of pay and supports needed.
Supported employment is conducted in a variety of settings, to include work
sites in which individuals, without disabilities, are employed.
Supported employment includes activities needed to sustain paid work at or
above minimum wage for recipients receiving waiver services, including
supervision and training. This training can focus on both the recipient’s needs,
as well as providing consultation to the employer to enhance supports natural
to the workplace rather than imposing paid supports. Supported employment
providers will immediately notify the recipient’s waiver support coordinator of
any changes affecting the recipient’s income. The service provider shall work
with both the recipient and the respective support coordinator to maintain
eligibility under the DD waiver, as well as health and income benefits through
the Social Security Administration and other resources.

Models of supported employment services include:
Individual Model - One person at a time approach to obtaining competitive
employment through the support of a job coach, employment specialist, or
consultant for job development, intensive training (Phase I) and systematic
follow-along supports (Phase 2). The individual model can apply to either
employment in the general work force or in development and operation of
establishing a business to be operated by the recipient.
Phase I is defined as time-limited supports needed to obtain a job and reach
stabilization. These billable support activities include:
(a) A situational assessment to determine a person’s employment goals,
preferences and skills;
(b) Job development for a specific recipient, matching the person with a job
that fits personal expectations; and
(c) Intensive, systematic on-the-job training and consultation focused on
building skills needed to meet employer productivity requirements,
learning behaviors and acceptance in the social environment of the job
setting, building job related supports with the employer from those
naturally occurring at that work site and other job related supports.
The number of hours of intervention is intended to diminish over the first few
weeks of employment as the supported employee becomes more productive
and less dependent on paid supports. Phase I ends after demonstration that
the supported employee has established job stability. The stabilization period
begins when the person has achieved satisfactory job performance as judged
by the employer, provider, Vocational Rehabilitation counselor (if applicable)
and the supported employee or when the need for paid supports diminishes
to fewer than 20 percent of weekly hours of employment. The stabilization
period is a minimum of 90 days following the onset of stabilization. If the
supported employee continues to perform the job satisfactorily the service
moves into extended, ongoing support services (Phase 2).
Staff is expected to provide varying intensities of services to each supported
employee, beginning with high intensity and fading to achieve stabilization.
Given the nature of this wide variation in level of support intensity and
duration needed per person, usual and typical staff to service recipient ratios
demonstrate that one staff person can support up to two to three supported
employees who are in Phase I at any given point in time. Phase I services
typically average 6-8 hours a day per recipient during the first week of
services. Average hours of service should fade to 1-2 hours a week in
preparation for transition to Phase 2. The average time period for Phase I is
24 to 25 weeks, but is different for each recipient depending upon need.

Phase 2 is defined as long-term, ongoing supports needed to maintain
employment indefinitely. These billable support activities include:
(a) Ongoing, systematic contacts with supported employees to determine the
need, intensity and frequency of supports needed to maintain
productivity, social inclusion and maintain employment;
(b) Remedial on-the-job training to meet productivity expectations,
consultation and refinement of natural supports or other elements
important to maintaining employment; and
(c) Related work supports such as accessing transportation and other
supports necessary for the recipient to maintain a job, or consultation to
family members or other members of a recipient’s support network
including employers and co-workers.
Phase 2 supports assume periodic life changes and personal tensions that
will cause job instability. Supports and services are designed to be dynamic
and to change in intensity and duration consistent with the needs of each
supported employee during periods of job instability and possibly during job
loss and re-employment activities. When supports needed to maintain
employment for a given person become too great in intensity or duration, it
may be necessary to move back to Phase I services to access a better job
match or seek employment alternatives. Moving to Phase I supports must
include a referral to Vocational Rehabilitation or the local school system (as
applicable) to seek required funding. Medicaid waiver funding shall be used
only if these alternative resources are not available.
During Phase 2 the service levels needed per supported employee vary
according to individual needs but typically average 1-2 hours a week per
recipient. Usual and typical demonstration of Phase 2 services assert an
expectation of a staff to service recipient ratio of one staff person supporting
up to twenty supported employees.
Group Models – Including:
1. Enclave - A group approach to employment where up to eight recipients
with disabilities work either as a group or dispersed individually
throughout an integrated work setting with supervision by the provider.
2. Mobile Crew - A group approach to employment where a crew, such as
lawn maintenance or janitorial, of up to eight recipients with disabilities
are in the community in businesses or other community settings with
supervision by the provider.
3. Entrepreneurial - A group approach to employment where up to eight
recipients with disabilities work in a small business created specifically by
or for the recipients.
Providers of supported employment services shall comply with requirements
found in the Medicaid Waiver Services Agreement, Core Assurances, and
those specified in this handbook.

Limitations

Supported employment services are limited to the amount, duration and scope
of the services described in the recipient’s support plan and current approved
cost plan. The provider shall render services at a time mutually agreed to by
the recipient and the provider. Off-hours support may occur as an alternative
or supplement to the on-the-job contacts.
Decisions to change the duration or intensity of the service to less than twice
monthly contacts, in the individual model of service delivery, or to terminate
supported employment services, shall only be made through consensus
among the recipient receiving services and his guardian; the Vocational
Rehabilitation counselor, if applicable; the APD Area Office or waiver support
coordinator; and the provider. If for any reason a recipient has terminated
services and requests reinstatement due to the need for ongoing supports, he
will be given priority for restoration of services.
Recipients working an average of less than 20 hours per week must have at
least a quarterly review. Documented attempts to increase work hours or
secure an appropriate job must be summarized quarterly, in the monthly
summary notes. Recipients should not remain in job development status for
more than a two month period. For recipients who remain in job development
status for more than two months, the supported employment coach will justify
monthly the reason(s) why employment has not been obtained and the
strategies planned for securing employment.

Phase I supported employment services are limited to eight hours, or 32-
quarter hour units per recipient a day.

Phase 2 supported employment services are limited to eight hours, or 32-quarter hour units per recipient per week.

Group model services are limited to eight hours, or 32-quarter hour
units per recipient a day.

Transportation of recipients to and from their job is not a component of
supported employment services but may be funded under transportation
services when no other community, natural, or generic support is available.
Separate payment for transportation services furnished by the supported
employment provider will not be made when rendered as a component of this
service.
Note: Refer to the transportation section description in this handbook for
additional information.

Documentation Requirements
Reimbursement* and monitoring documentation to be maintained by the
provider:
1. *Copy of claim(s) submitted for payment;
2. *Service log
3. *Monthly summary;
4. Documentation, in the form of a letter from Vocational Rehabilitation (VR)
Services or a case note detailing contact with a named VR representative,
the date, summary of conversation, etc., indicating a lack of available VR
funding for supported employment;
5. *Implementation employment plan must be completed at the time of first
claim submission and annually thereafter at the time of support plan
update, and at any time updates and changes are made before they are
implemented; and
6. Annual report.
In addition to the minimum required components of the individual
implementation plan described in the definitions section of this handbook, the
individual implementation plan for supported employment service must also
contain the following:
1. Documented review by the provider to furnish information and supports for
the recipient to make an informed choice in the type of work preferred, job
changes or career advancement opportunities.
2. For recipients receiving services in the individual model there must be
documented bi-weekly contacts, either on the job site or in another setting,
to monitor the needs and provide supports for retraining, adequacy of
workplace supports and relationships, and job satisfaction or desires for
job change should be noted. The monthly summary must clearly
reference these contacts and the specific supports provided.
Documentation to be submitted to the waiver support coordinator by the
provider:
1. Copy of service log, monthly;
2. Implementation and employment plan at the time of first claim submission
and annually thereafter;
3. Performance data on the selected service outcomes projected in this
document; and
4. Copy of annual report prior to annual support plan update.
If the provider plans to transport recipients in his private vehicle, at the time of
enrollment, the provider must be able to show proof of: 1) a valid driver’s
license, 2) car registration, and, 3) insurance. Subsequent to enrollment, the
provider is responsible for keeping this documentation up-to-date.
*Indicates reimbursement documentation.

Place of Service

Supported employment services are provided in the recipient’s place of
employment in the community or in a setting mutually agreed to by the
supported employee, the employment coach or consultant and the employer.
Should the employment location of a recipient change, the provider shall notify
the recipient’s waiver support coordinator within five working days.

Special Considerations
Supported employment services furnished under the waiver are not available
through programs funded by the Rehabilitation Act of 1973 or Public Law 94-
142. Documentation to this effect will be maintained in the file of each
recipient receiving this service.
When the supervisor of a mobile crew or enclave does not meet the
qualifications for a supported employment coach, although the recipient meets
the criteria for supported employment, the support service must be billed as
adult day training off-site, rather than supported employment.
Supported employment services are defined as competitive employment,
which may be performed on a full-time or part-time basis, in an integrated
setting, for which an individual is compensated at or above minimum wage but
not less than the customary wage, and at a level of benefits paid by the
employer for the same or similar work that is performed by trained, nondisabled
individuals.
Providers of supported employment – group model services will bill for each
recipient based on the published stepped rate for the service. The group rate
shall be determined based on from two to eight recipients receiving the
service.
Providers of supported employment – individual model services will bill, based
on a one to one ratio, the rate established for the service in the published rate
system.
Payment will not be made for incentives, subsidies, or unrelated vocational
training. The supported employment vendor will not bill for supports provided
by the employer.

Supported Employment Services Provider Requirements

Supported Employment Services Provider Requirements

Provider Qualifications
Providers of supported employment services may be either independent vendors,
solo providers or agency vendors.
Independent vendors, solo providers and employees of agencies who render this
service shall have a bachelor’s degree from an accredited college or university
with a major in business; nursing; education; or a social, behavioral or
rehabilitative science. In lieu of a bachelor’s degree, a person rendering this
service shall have an associate’s degree from an accredited college or university
with a major in business; nursing; education; or a social, behavioral or
rehabilitative science and two years of experience. Experience in one of the
previously mentioned fields shall substitute on a year-for-year basis for the
required college education.
Licensure and registration is not required.

Training Requirements
Agency providers are required to attend 12 hours of pre-service training and eight
hours of annual in-service training related to supported employment.
Agency employees and independent vendors and solo providers enrolled after
March 01, 2004 are required to attend 18 hours of pre-service training prior to
assuming job responsibilities and eight hours of annual in- service training.
Training will include the approved curriculum entitled, “Supported Employment
and Natural Supports, A Florida Training Curriculum, 2001 Edition”, or an
equivalent training curriculum, as approved by APD.
Individual vendors must attend at least one supported employment related
conference or workshop prior to certification and eight hours of annual in-service
training related to supported employment. Proof of annual or required updated
training shall be maintained on file for review.
The provider is responsible for all training requirements outlined in the Core
Assurances.
Note: Refer to the Core Assurances in Appendix A for the provider training
requirements.

Projected Service Outcomes
Projected service outcomes are goals used to determine through monitoring and
review the accomplishments of providers and the effectiveness of service
provision.
Provider assists individuals in securing employment according to their desired
outcomes, including type of work environment, activities, hours of work, level
of pay and supports needed.
Recipients in the individual model, during follow along (phase 2) do not need
paid job coaching in excess of an average of 20 percent of the recipient’s
average work hours.

Recipients receiving supported employment services achieve goals on their
support plan throughout the year.
Recipients receiving this service are assisted in progressing on their chosen
career path.
All recipients served who have responded to the annual satisfaction survey
are satisfied with their services based on the results or that the provider has
addressed any concerns raised during the survey.