Best Practices Guide: IDD Supported Employment

Cardinal Innovations Healthcare Best Practices Guide: IDD Supported Employment

Table of Contents

Introduction ...... 3

Employment in ...... 4

Readiness Issue/Determining Readiness ...... 5

Role of the Job Coach ...... 6 Initial Supported Employment-Individual services may include any of the following: ...... 6 Long-Term Follow-Along Supported Employment-Individual services include: ...... 9

Comparison to and Integration with Other Services ...... 10

Age Group Learning and Life Stage Considerations ...... 11

The Role of Contextual Influences ...... 12

Addressing Behavioral Needs in Supported Employment ...... 12

Preference Assessment Across the Lifespan ...... 13

Level or Intensity of Supported Employment Service ...... 14

Supported Employment Funding Sources ...... 15

Vocational Rehabilitation Services ...... 16

References ...... 19

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Introduction Supported Employment (SE) options have enabled individuals with significant support needs to become employed in the community. In the United States, the definition of Supported Employment is as follows:

1. Supported Employment means: a. Competitive employment in an integrated setting with ongoing support services for individuals with the most severe disabilities i. For whom competitive employment has not traditionally occurred or for whom competitive employment has been interrupted or intermittent as a result of a severe ; and ii. Who, because of the nature and severity of their disabilities, need intensive Supported Employment services and extended services after transition in order to perform this work; OR b. Transitional employment for individuals with the most severe disabilities due to mental illness.1,5

We know now that individual Supported Employment is superior in terms of program outcomes,1,2 philosophy, and cost.3,4 In the individual approach, a professional Vocational Rehabilitation specialist (often referred to as a job coach) provides an array of supports to assist a person with a significant disability in obtaining and maintaining competitive employment in the community. The initial component of the service involves assisting the job seeker with 1) identifying his or her abilities and how these may relate to work and 2) specifying vocational interests and preferences.

Next, job development services geared toward helping the person secure work are offered. Sometimes, existing positions within a business are pursued and, at other times, employers may be approached about creating a specific position for the job seeker. Typically, the job coach first meets with an employer to learn more about a business’ operations and potential labor needs. Then, when viable opportunities begin to emerge, a meeting may be set up between the employer and the job seeker. At this point, the typical pre-employment process begins, which involves completing an application and participating in an interview, all of which is supported by the job coach. The level of involvement will vary from business to business and is dependent on the skill level of the job seeker. If a job is found or developed that is a suitable match for the job seeker and the employer is agreeable, employment is secured.

All parties involved benefit from competitive and integrated employment, which provides the individual with a disability a real job, benefits, and the dignity that arises from gainful employment. With SE, the employer gets a good employee and receives specialized support for job acquisition and retention. The family can see the newly employed family member in a fully competent role in the workplace. Finally, taxpayers spend less money than they would to support the individual in a segregated day program. Inherent in the SE process are basic values. See Table 1

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Table 1. Supported Employment Values

Values Explanation Presumption of employment Everyone, regardless of the level or the type of disability, has the capability and right to a job Competitive employment Employment must occur within the labor market in regular community businesses Self-determination and control People with disabilities must choose and regulate their own employment supports and services, which will ultimately lead to career and life satisfaction Commensurate wages & benefits People with disabilities should earn wages and benefits equal to that of coworkers performing the same or similar jobs Focus on capacity & capabilities People with disabilities should be viewed in terms of their abilities, strengths, and interests rather than their disabilities Importance of relationships Community relationships both at, and away from, work leads to mutual respect and acceptance Power of supports A conviction that people with disabilities need to determine their personal goals and receive assistance in assembling the supports necessary to achieve their ambitions Systems change Traditional systems must be changed to support self-determination, which is vital to the integrity of Supported Employment Importance of community People need to be connected to the formal and informal networks of a community for acceptance, growth, and development

Wehman, P. Supported Employment: What is it? Journal of Vocational Rehabilitation, 37, p. 141.

In addition, all individuals have both a need and a right to develop a meaningful day. Most individuals need to feel a sense of productivity and that they are contributing members to society. Supported Employment provides such an opportunity. In addition to the structure, routine, physical activity, and mental activity, SE provides not only a meaningful day, but it also helps individuals enhance and maintain their skills and independence.

Employment in Disabilities As of 2018, over 85% of people6 diagnosed with an intellectual or developmental disability were either unemployed or underemployed. As well, over two thirds of people diagnosed with a disability live below the poverty line.6 Many people with I/DD are placed in position that do not pay competitive wages or in sheltered workshops and prevocational type settings that offer limited options for growth or integration into the community. Not only does this limit opportunity for career growth but continues to reinforce negative stereotypes regarding those with I/DD as well as contribute to an ongoing cycle of poverty.

Western culture places a strong emphasis on work ethics and the intrinsic value of work, which is often denied or provided with artificial limitations for those with disabilities. This is compounded by fears from family members or individuals themselves that they may lose supports such as Medicaid, transportation, or other assistance if they earn

Page 4 of 20 Cardinal Innovations Healthcare Best Practices Guide: IDD Supported Employment too much money. Evidence indicates that integrated employment options provide benefits such as moving “an I/DD individual’s daily focus away from formal, paid supports and toward an integrated, self-sustaining life alongside individuals without disabilities.”7

Readiness Issue/Determining Readiness A person with I/DD does not have to be determined to be ready for job placement in order to be ready to begin Supported Employment (SE) services. Ideally, a provider should engage in an Employment First policy.8 This means that employment in the “general workforce” at a competitive wage is the first and preferred option.9 It is assumed that the person with I/DD can work until proven otherwise, rather than assuming that they must demonstrate “readiness to work.”10

Studies support that a rapid job search with individual placement is generally more successful than providing more lengthy pre-employment assessments, training, or counseling. There are very few pre-employment assessments for those with I/DD and limited information regarding their usefulness or efficacy in determining “readiness” for employment. Although pre-vocational services can be helpful for some individuals, they are not necessary for all participants. Pre-vocational services should be time limited and provided in a community-based setting with the goal of creating a pathway for competitive employment.10

Areas that can provide some utility for assessment for job readiness include the following: 1. Assisting the individual with identifying barriers: a. Childcare, transportation, stable housing b. Mobility and access 2. Assessing soft skills that may need support or pre-vocational training: a. Hygiene, punctuality, workplace appearance b. Communication skills c. Social skills 3. Identifying areas of interest and focus on member choice for job roles: a. Formal career assessments b. Exploration/interest in secondary education c. Skills assessment d. Self-determination i. The individual should be involved in each step and career interests should not be determined by others e. Language should be at their level of understanding 4. Career exploration: a. Shadowing, touring businesses, attending informational sessions 5. Identify specific needs for individual based on interests a. Example: A person interested in designing jewelry may need an (OT) assessment to identify supports for poor fine motor skills. b. Example: Someone with ASD who is interested in working in a loud environment may need assistive devices such as noise-canceling headphones. 6. Hard skills: a. Less attention should be spent on specific job skills since many of these can be learned while working.

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Role of the Job Coach A job coach is a paid support individual who helps people with disabilities learn, accommodate, and perform their work duties. A job coach may work with people individually or in small groups. In addition to working on skills related to performing specific job tasks, a job coach also helps with workplace social skills. The coach will assess the worker’s strengths and needs or may use information available from other assessments.

Typical job coach duties include: 1. Assisting a new worker to learn their job tasks 2. Identifying natural supports, accommodations, and that will help the worker be more independent in their job 3. Helping the worker to become socially included in the workplace 4. Teaching the worker how to be a self-advocate in the workplace 5. Functioning as a consultant to the worker and the employer

In addition to the typical job coach duties, there are also roles or duties job coaches should never perform. Job coaches should never: 1. Perform any management or supervisory role in the workplace 2. Perform job tasks for or with the worker to increase work production or quality 3. Show up unexpectedly or spend unnecessary time at the workplace

Specifically, the role of the job coach depends on the type and level of service (e.g., Medicaid, B3, state-funded) being provided. Some examples by phase of service are included below.

Initial Supported Employment-Individual services may include any of the following: 1. Explore and pursue employment a. Explore and make an informed choice about pursuing competitive integrated employment. When this service is used to help a beneficiary explore and make an informed choice about pursuing competitive integrated employment, this service includes, at minimum: i. Sufficient, but time-limited job and career exploration activities to identify a person’s specific interests and aptitudes for paid work, including experience and skills transferable to competitive integrated employment; ii. Uniquely arranged business tours, informational interviews, and/or job shadows that are specifically related to the person’s identified interests, experiences and/or skills to explore potential opportunities for competitive integrated employment in the person’s local area; iii. Introductory, basic education on the numerous work incentives for individuals receiving publicly funded benefits (e.g., SSI, SSDI, Medicaid, etc.); iv. Introductory education on how Supported Employment-Individual services work (including Vocational Rehabilitation services). Educational information is provided to the person and the legally responsible person (LRP) and/or most involved family member(s), if applicable, to ensure LRP and/or family support for the person’s choice to pursue competitive integrated employment. The educational aspects of this service shall include addressing any concerns, hesitations, or objections of the person and the LRP and/or most involved family member(s), if applicable.13

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Targeted and time-limited employment navigation assistance that is designed to assist a beneficiary who wants to pursue and obtain competitive integrated employment to access needed employment services and supports from non-Medicaid sources (e.g. Vocational Rehabilitation; NC Works programs and services; ; ; Work Incentives Planning and Assistance (WIPA) program).

2. Discover employment opportunities a. Meeting face to face with the individual, parent, or LRP to get familiar with one another. b. Have an open discussion to determine strengths, weaknesses, jobs of interest, job location, previous employment, job skills, volunteer work, and specialized trainings. c. Gather information from previous employment skills or volunteer work to support the individual in building a resume, if any. d. Use community libraries or NC Works Career Centers as a resource to support the individual in building a resume.

3. Choose and acquire employment a. Successfully seek, choose, acquire, increase, and/or advance in competitive integrated employment, which may include career/educational counseling, discovery, job shadowing, job development/placement, customized job development, training or assistance in resume preparation, job interview skills and/or learning other skills necessary for success, and assistance in the use of educational resources and development of study skills. b. The employment or self-employment outcome must be consistent with the individual’s interests, preferences, strengths, skills, and conditions identified as necessary for success, in order to maximize the likelihood of sustained and satisfying work. Job finding is not based on a pool of jobs that are available or set aside specifically for individuals with disabilities.

4. Search for employment opportunities a. Support individual on the computer to search for desired jobs. b. Assist in researching the jobs of interest. c. Explain to the individual the responsibilities of the job interested in, pay rate and job location. d. Drive to the location of a desired job to allow the individual to see how the job is performed. e. Have conversations about the job positions seen and if there remains an interest to be employed. f. Determine if the jobs of interest are reasonably close to of the individual’s residence. g. Assist with completing application(s) for employment of a desired job in person or online. h. Write down the job applied for, location of job and person to contact if available. i. Follow up on jobs applied for, if no one has responded in a timely manner. Discuss with the individual, parent or LRP the proper attire for interviews.

5. On the job training/coaching a. Initial coaching and employment support activities enable an individual to complete initial job training, develop skills necessary to maintain employment, and transition successfully to Long-Term Follow-Along Supported Employment-Individual services. b. These activities typically include but are not limited to assistance in: i. Learning job tasks (e.g. systematic instruction);

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ii. Learning company policies and expectations, developing skills for traveling to/from work, and iii. Getting to know/interacting effectively with supervisors and co-workers. Initial coaching and employment support activities should be expected to continue until the person successfully completes any probation period that the employer may have. c. Fading of initial coaching and employment support activities should be considered from the onset of job coaching and some level of fading should begin as the coach works with the individual. Also, incremental fading should be expected to continue over time, as the person becomes more independent on the job and can rely on natural supervisors and co-workers for needed supports, until fading has been maximized and/or the person completes their probation period at which point the person should transition to Long-Term Follow-Along Supported Employment-Individual services.14 d. Feedback regarding the performance and integration of the individual into their workplace should be obtained from the employer through employee evaluations or other means that provide information on the level and type of coaching and support that the individual requires. The transition to Long-Term Follow- Along Supported Employment- Individual services should typically occur within one year of the individual starting competitive integrated employment. e. As part of initial coaching employment support activities, supports include consultation, technical assistance, and education for the employer, as well as supervisors and co-workers. This can include education on reasonable accommodations and other strategies that can contribute to long-term success of the competitive integrated employment situation and the satisfaction of the employer.

6. Duties of the job coach at job start a. Communicate with the individual, LRP, agency QP, and Cardinal Innovations care coordinator that there is a job start. b. Support the individual in speaking with the employer to get accommodations, scheduled work hours, job description, and work uniform requirements; complete employee computer trainings if needed. c. Communicate job description with agency QP to create goals for employment. d. Train the individual to identify management, check work schedule, clock in/out, perform job duties by providing prompts, hand over hand, or role playing. e. Support individual in building relationships with others in the workplace. f. Discuss and support the individual with any work issues. g. Communicate issues on the job, job performance, or any changes with agency QP and LRP. h. Be present for employee evaluations or discussions with individual and management. i. Provide ongoing support on the job and justify the need for support at scheduled meetings with agency QP, LRP, and care coordinator.

7. Self-employment a. Services to assist an individual to achieve self-employment or ownership of a micro-enterprise. This assistance consists of: i. Aiding the individual to identify potential business opportunities; ii. Assistance in the development of a business plan, including potential sources of business financing and other assistance; iii. Assistance, based on needs related to disability, in launching the self-employment or micro- enterprise venture;

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iv. Identification of the long-term follow-along supports that are necessary for the individual to maintain self-employment or operate the micro-enterprise.

Long-Term Follow-Along Supported Employment-Individual services include: 1. Maintaining employment a. Coaching and employment support activities necessary to enable an individual to maintain competitive integrated employment, such as on-the-job supports that do not replace or discourage natural supports, services necessary to maintain and improve skills needed to complete job tasks and supports to manage impact of disability in relation to employment. b. Feedback regarding the performance and integration of the individual into their workplace should be obtained from the employer at regular intervals through employee evaluations or other means that provide information on the level and type of coaching and support that the individual requires. A focus on identifying and implementing strategies for fading should continue in Long-Term Follow-Along Supported Employment-Individual services.7

2. Maintaining own business a. Ongoing assistance, counseling, and guidance for an individual who is self-employed or operates a microenterprise.7

3. Ongoing supports a. Ongoing employer consultation, technical assistance, and education, including supervisors and co-workers as needed, with the objective of ensuring long-term success of the competitive integrated employment and the satisfaction of the employer and supported employee. This includes proactively identifying issues and offering assistance to resolve these issues in order to prevent the supported individual’s loss of employment and advising the employer regarding reasonable accommodations and other legal requirements. b. The amount and duration of Long-Term Follow-Along Supported Employment-Individual services authorized should be individually determined and based on individual need. Services must involve, at minimum: i. Monthly face-to-face contact with the supported employee, which may or may not be at the workplace, depending on the preferences of the individual and his/her employer; ii. Monthly contact with the employer. Long-Term Follow-Along Supported Employment-Individual services may be needed on an ongoing basis to meet specific and well documented needs of supported employees and/or to provide for minimum contacts with the supported employee and employer as a preventative measure to avoid otherwise preventable job loss.7

If Long-Term Follow-Along Supported Employment-Individual services are discontinued at some point because it is determined the supported employee no longer has a need for these services, a re-authorization of the services may be needed at a future point if: • The individual’s job duties change • A supervisor or key co-worker leaves • The individual’s disability or health creates a new need for Long-Term Follow-Along Supported Employment- Individual services • There is an issue that must be resolved in order to ensure the job is sustained.

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Long-Term Follow-Along Supported Employment-Individual services that are needed to address medical, behavioral, and/or physical support needs shall require documentation of such needs and accompanying narrative/documentation in the ISP supporting the need for Long-Term Follow-Along Supported Employment- Individual services as the most appropriate and viable option for enabling the individual to maintain competitive integrated employment.7

Comparison to and Integration with Other Services A Meaningful Day11 is an important concept for supporting those with I/DD. Creating meaningful days for our members includes learning and developing new skills, pursuing interests, connecting socially with others, and empowering the person to find purposeful experiences. In general, most paid meaningful day services fall into either community- or facility-based categories as either work or non-work services. Ideally, an individual who is not able to participate in integrated competitive employment on a full-time basis should have the opportunity to engage in services that allow for a meaningful day. The amount of time and scheduling of these services should be person centered, based on their interests, preferences, desires for social inclusion, and tolerance for activities.12

• Community-based non-work: This may include services such as Community Networking, which can increase access to community activities in an integrated setting, as most of the people participating with the individual are not paid staff nor do they have a disability. These activities allow individuals to develop social relationships and explore interests through volunteer work, as well as develop hobbies, and overall become more engaged in their community. • Facility-based work: This includes services such as Adult Developmental Vocational Program (ADVP) which are often referred to as “sheltered workshops.” Most employees in this setting will have a disability and need frequent supervision and supports in order to remain engaged in their labor. Long-term studies have demonstrated that most individuals with I/DD do not graduate from these placements into integrated, competitive employment. In fact, the National Disability Rights Network has advocated against use of sheltered workshops. The Rehabilitation Services Administration does not recognize these placements as having successful outcomes, and the Centers for Medicare and Medicaid no longer cover these services. • Facility-based non-work: This includes services such as Day Supports Group (DSG) and Psychosocial Rehabilitation (PSR) which are typically non-integrated settings where most of the participants have a disability or are paid staff. These services may allow for some participation in community activities. Most participants require frequent supervision and supports to remain engaged in activities and to ensure their health and safety. These services may include some pre-vocational activities such as financial skills and social skills, resume creation and writing, and even job searches.

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Age Group Learning and Life Stage Considerations Success in finding and sustaining employment for adults with I/DD is an undertaking that has its roots in the skills learned in early life.15 There are many seemingly disparate factors that can combine to enable an individual to achieve employment and, most importantly, to sustain that employment. Thus, it is critical for the treatment team to engage with the family and start planning interventions that target these key skills from an early age. Several key considerations and topics are to be addressed at each major stage of life as shown in Table 2.

Table 2

12 and teens 20s 30s 40s 50+ under

Parent Advanced Self Living Living Work Retirement Education Care Arrangements Arrangements

School Vocational Health Review Living Work Work Success Plans Management Arrangements

Basic Self Transition Health Enhanced Self Support to Learned Relationships Care Planning Management Care Skills

Enhanced Self Community Career/Life Nutrition Sex Ed Enhanced Self Care Care Connections Fulfillment

Learning/Earni Learning/Earn Enhanced Self End of Life Planning & Exercise ng ing Care Resources

Money Transportatio Financial

Management n Planning

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The Role of Contextual Influences Studies have shown that contextual influences played a significant role in predicting success with Supported Employment. Among the strongest factors are inclusive education during childhood and living in an area with a larger population. While these factors cannot be overcome easily for some, there are several other attainable skills that were shown to have significant positive impacts such as: meal preparation, self-care, and housekeeping skills. In addition to the obvious benefits of these skills being directly applicable to employment in a restaurant or hospitality setting, the base operations that lie beneath these skills consist of multiple functions that can be very beneficial for success in a job setting, e.g., skills like following directions, memory, planning, and organizing. These self-directed routines are strong indicators of the ability and desire to work independently.15

Inclusive education environments share many of the same traits that will be needed in a competitive employment setting. Social competency, adaptive behaviors, and other skills learned with typically developing peers can improve employment prospects in adulthood.16

Addressing Behavioral Needs in Supported Employment As previously stated, Supported Employment is founded on the belief that anyone can work if they are provided the right supports.17 While helping people manage behavioral needs is an essential component of Supported Employment, there have been few research studies that have examined how to address behavioral needs in Supported Employment. Earlier data regarding the employment of people with disabilities has suggested that the management of behavioral needs or challenges was a longstanding barrier to employment and a reason that many people with disabilities were unable to maintain their employment.18 However, as Supported Employment began to grow in the 1980s and 1990s, it was recognized that job coaches employed effective strategies for helping people to manage challenging and difficult behaviors.19

The Supported Employment: Participant Training Manual20 provides several good strategies for addressing behavioral needs for people receiving Supported Employment and further supports the notion that people do not need to be “ready” for Supported Employment by having no instances of challenging behaviors. While it is important that people be safe in their work environments, the concept of safety is often overinflated by systems, providers, caregivers, and loved ones who are worried that any challenging behaviors may pose a safety risk. As previously discussed, each individual’s needs should be evaluated individually and efforts made to provide the person with behavior supports in all settings, including their place of employment.

“[W]hen an employee engages in workplace behaviors described as problematic, disruptive, or inappropriate, the job coach may need to consider behavioral workplace support strategies, instead of teaching just work tasks.”18 There are many unique situations and circumstances to consider, however it is important to make sure that the person’s dignity and privacy are respected at all times when addressing behavioral needs. Behavioral management strategies can be addressed with the individual’s other team members. The following is general guidance and should not replace individual-specific procedures that are established through the person-centered planning process: 1. If the person already has an established positive behavioral support plan (BSP) or other behavioral interventions in place, those should be implemented in the workplace. 2. If no behavioral supports are formally established, the job coach should first seek to define the behavior in observable and measurable terms (e.g., After getting corrective feedback from his supervisor, Robert went into the restroom and flooded it by stuffing the toilet with toilet paper and flushing it multiple times).

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3. In addition to the needs of the member, it is important that the challenging behavior be assessed from the needs of the employer. Some examples include: 1) workplace policy violations, 2) previous supervisory feedback given to the member by the employer, 3) how the employer typically deals with these issues in the workplace (“What usually happens?”), and 4) whether the employer is open to feedback from the job coach regarding the issue?

When considering risky behaviors in the workplace, “… the Americans with Disabilities Act (ADA), the term Direct Threat applies to any employee actions considered a significant risk to the health or safety of themselves or others, which cannot be eliminated by reasonable accommodation. Factors considered when assessing a situation as a direct threat include: 1. Duration of the risk. 2. Nature and severity of the potential harm. 3. Likelihood that the potential harm will occur. 4. Imminence of the potential harm18.”

When making these determinations, it is important to remember that the threat is reduced or eliminated if it can be addressed through reasonable accommodations. An example is a member who is easily triggered by noise or a lot of people. A potential reasonable accommodation would be for the member to wear noise-cancelling headphones or be relocated to a work area that has fewer people and distractions.

As with all social settings, an individual workplace has a certain set of social norms and expectations. The range of acceptable behavior in one workplace may be very different from another workplace. Part of what makes for successful employment is finding a match between the employer and the employee, and this includes a match with the social environment, e.g., number of people, gender of peers, etc.

In addition to individual factors, other things to consider when behavioral needs arise in the workplace is whether the fit between the employee and employer is appropriate or whether there are factors about the immediate work setting which may be contributing to the person’s behavioral issues.

Preference Assessment Across the Lifespan The majority of research regarding the assessment of preferences across the lifespan in intellectual and developmental disabilities (I/DD) has been specific to Autism Spectrum Disorder (ASD). In particular, the research has been specific to assessing people’s restricted interests in order to try and expand the options for positive behavioral supports.21

More broadly, the concept of preference assessment has been recognized as an important factor in the person- centered thinking and planning process for people with I/DD. All people have preferences in terms of the types of things they enjoy such as foods, leisure activities, social activities, colors, clothing, temperatures, etc. Historically, professionals and congregate care settings have ignored or failed to ask or assess for preferences among people with disabilities.22 As the knowledge and importance of these assessments grew, along with person-centered planning processes, many providers and settings continue to forget that these assessments are essential throughout a person’s life.

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Some of the best advice regarding preference assessment comes from the Applied Behavior Analysis (ABA) literature. Suggested preference assessment procedures vary widely among professionals and providers, but the basic principles are as follows: 1. The frequency of assessment should be as often as is needed; 2. The purpose of the assessment should be clear and clearly explained to the person being assessed; and 3. Once preferences are determined, they should be incorporated into all aspects of goal and behavior planning processes.

Though it is important to conduct formal preference assessments, informal preference assessments can be conducted much more frequently and may occur at the beginning of goal/skills training, especially when a person is learning new job tasks or transitioning from work to other activities. Informal preference assessment sometimes also occurs before placing a demand (e.g., packing up to leave work) and in these contexts the job coach can ask the person what they would like to do when they complete the task (e.g., person wants to get a coffee) and then provide the preferred item after completing the demand. When people have adequate expressive language, the job coach can check in frequently with the person about their preferences by simply asking.23 For members who are nonverbal, visual cues to depict options can be used. Also, it is important to watch for times when a person rejects or no longer seems to derive any enjoyment from something that they used to enjoy.

Level or Intensity of Supported Employment Service The expected outcome of Supported Employment (SE) is that individuals will maintain the appropriate level of employment (either full or part time) based upon their skills, interest, and abilities. Supports for people with disabilities are individualized and include: • Prevocational activities • On-site services designed to help ensure success and satisfaction at work • Employment maintenance activities

Some people with I/DD may require occupational, physical, or speech therapies along with job training programs to enable them to best engage in employment. Since the ultimate goal of SE is to promote workplace independence and integration, a plan for fading supports is needed from the very beginning of SE services.

The Supported Employment: Participant Training Manual20 provides a good overview of the importance of fading and level of supports over time. This resource describes several essential components that should be considered when fading services: 1. Begin evaluating fading during the initial phase of SE 2. Discuss the fading plan/timeline with the member and employer 3. Make sure natural supports [in the workplace] are in place before beginning fading 4. Everyone should know how to contact the job coach 5. Fade services incrementally 6. Conduct “what if” scenarios and role-play scenarios with the member [and think about plans to address future needs should they arise (e.g., loss of a job, extended absence/illness)] 7. Consider needs for long term or ongoing supports

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Another effective method that can assist with fading, help with transitions, assist in learning new skills, and increase independence is the development of social stories. “Social stories describe a situation, skill, or concept in terms of relevant social cues, perspectives, and common responses in a patient and reassuring manner that is easily understood by its audience.”24 In other words, social stories use words or images to explain specific occurrences, behaviors, social interactions, concepts, or skills. They are designed to benefit those with developmental delays, social issues, autism, or other difficulties with comprehension.

Supported Employment Funding Sources Currently, within the authorization authority of Cardinal Innovations Healthcare, there are three funding sources and several service definitions related to Supported Employment (SE) and other employment-related services for people with I/DD. Each of these levels and/or intensity of service is summarized in Table 3.

Table 3. Funding sources and service definitions related to Supported Employment and other employment-related services for people with I/DD

Funding Level/Intensity of Description Source/Definition Supported Employment Innovations Waiver Initial Supported Services that support a beneficiary to explore and make an (Clinical Coverage Employment-Individual informed choice about pursuing competitive integrated Policy 8-P)25 employment. Innovations Waiver Long-Term Follow-Along Services that provide assistance, based on individual (Clinical Coverage Supported Employment- circumstances and need, to maintain, increase and/or Policy 8-P)25 Individual advance in competitive integrated employment. Cardinal Innovations Initial Supported Includes: Healthcare (b)(3) Employment 1) Pre-job training/education and development activities. Services26 2) Assisting a member in developing and operating a micro- enterprise. 3) Coaching and employment support activities that enable a member to complete initial job training or maintain employment. Cardinal Innovations Long term follow-up Includes: Healthcare (b)(3) supports 1) Coaching and employment support activities that enable a Services20 member to maintain employment in a group such as an enclave/small group or a mobile crew. 2) Ongoing assistance, counseling, and guidance for a member who operates a micro-enterprise once the business has been launched. 3) Assisting the member in maintaining employment. 4) Employer consultation with the objective of identifying work-related needs of the member and proactively engaging in supportive activities to address the problem or need.

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NC MH/DD/SAS State- Supported Involves arranging for and supporting paid work for an Funded Service Employment—IDD— individual in a job which would otherwise be done by a Definitions: Individual nondisabled worker. The service includes intensive 12/15/1927 involvement of staff working with the individual in the work setting or in support of the individual so that the individual's employment can be maintained in a normal community environment. NC MH/DD/SAS State- Adult Developmental Provides organized developmental activities for individuals Funded Service Vocational Program with I/DD to prepare the individual to live and work as Definitions: (ADVP) independently as possible. The activities and services of ADVP 12/15/1925 are designed to adhere to the principles of normalization and community integration. These may include personal and community living skills development; compensatory or adult basic education; training in cognitive, communication, and motor skills; use of leisure time; vocational evaluation; and adjustment, work skills training, and paid employment. NC MH/DD/SAS State- Long Term Vocational Begins after the intensive phase of job coaching funded Funded Service Support Services through the Division of Vocational Rehabilitation ends. Definitions: (LTVSS) (Extended Includes services provided to or on behalf of the individual 12/15/1925 Services-IDD) both on and off the job site to ensure ongoing employment success and career growth. 1) Coaching and employment support activities that enable an individual to maintain employment. 2) Ongoing assistance, counseling, and guidance for an individual who operates a micro-enterprise or small business. 3) Monitoring, supervision, assistance in job tasks, work adjustment training, and counseling as needed to assist the individual in maintaining employment. 4) Consulting with the employer to identify work-related needs of the individual and proactively engage in supportive activities to address the problem or need.

With all services, it is important to remember that that the individual must want to be engaged in employment and it should be a goal in her or his Individualized Support Plan (ISP) or Person-Centered Plan (PCP). In addition, retirement or reduced working hours can be a normal part of a person’s lifespan. As a person with I/DD ages, they may wish to reduce their hours or stop working to pursue other interests (e.g., increased leisure activities). In some cases, this may occur due to advancing illness or a change in preferences. Regardless of the reason, providers and caregivers should work with the person to see how their current needs and preferences can be met, which may result in stopping Supported Employment services.

Vocational Rehabilitation Services The North Carolina Division of Vocational Rehabilitation Services (DVRS) helps people with disabilities achieve their employment goals in competitive, integrated employment through counseling, education, training, job placement

Page 16 of 20 Cardinal Innovations Healthcare Best Practices Guide: IDD Supported Employment assistance, assistive technology, and many other services. The general information regarding traditional Supported Employment (SE) services is shown in Table 4.

Table 4. Overview of Vocational Rehabilitation Services

Population Served • Emotional disabilities • Substance use disorders • Cognitive/learning disorders • Developmental disabilities • Sensory disabilities • Chronic physical disabilities Eligibility to be served through Vocational Rehab • Age 14 and over (Traditional SE will be delayed until moving closer to high school graduation, but other services can be provided.) • Must have documented disability presenting barriers to employment • Must require a VR service to reach successful employment outcome • Must benefit from service provided • Must have at least 3 functional capacity limitations Referral • Contact local VR agency • Anyone can refer What does it look like? • Individualized Plan for Employment (IPE) • Counseling and guidance • Job skills assessment • Training - interview skills, resume assistance • Job search assistance • Job coach on site, job training on site o Job coach works for provider agency (not VR) • Rehabilitation technology • Occupational/post-secondary education/training • Benefits counseling • Support services (must meet financial needs test) o Work clothing, short term transportation, short term childcare and more • Once employed, VR funding typically stops after 90 days on the job. LME/MCO picks up long term funding via authorization for services based on medical necessity Expected Outcome • Based on Individualized Plan for Employment (IPE) • Must be in a competitive integrated setting

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For more information about VR services, visit https://www.ncdhhs.gov/assistance/disability-services/employment- services-for-people-with-disabilities or https://files.nc.gov/ncdhhs/documents/files/VRValueRealized%28WR2%2912.15.2017.pdf

In addition to the traditional SE services, DVRS also has special vocational services for people who are deaf, hard of hearing, or late-deafened and for youth and students. To learn more about these programs please visit:

• Individuals Who are Blind Vocational Rehabilitation Services for the Blind https://www.ncdhhs.gov/assistance/vision-loss/vocational-rehabilitation-for-blind • Individuals Who Are Deaf, Hard of Hearing, Late-Deafened https://www.ncdhhs.gov/documents/employment-services-people-who-are-deaf-hard-hearing-late-deafened • Youth and Student Services https://www.ncdhhs.gov/document/ncvr%27s%20youth%20and%20student%20services

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