Interim Report - Day Program Rate Work Group (April, 2009)

Introduction

This Interim Report presents the findings to date of the Day Program Rate Workgroup of the Statewide Advisory Council Rate Committee and its review of day programs.  The Work Group's charges were to:

  1. Identify and recommend changes in the methodology that could have a short-term and immediate effect of enhancing services and supports in the community services system in ways that advance the adequacy, quality, and quantity of this part of the system to the forefront.
  2. Identify additional areas of potential changes in the reimbursement methods that could be considered for the longer term.

The reader is referred to the Statewide Advisory Council (SAC) Rate Committee Interim Report Overview of Rate Committee for a discussion regarding the overall framework of the following principle charges:

  1. Develop rate proposals that are adequate, fair, and equitable.
  2. Create statistical models for each rate component or sub-component by identifying the data elements and processes.
  3. Break proposals into part that can be independently implemented.
  4. Develop rate proposals that are "shelf ready" to implement as opportunities to do so are presented.

This paper reflects an overall recommendation followed by two major sections of findings and recommendations from the Work Group:

  1. Recommendations - Section 1 includes items the Work Group has reviewed
  2. Additional Review and Research Recommendations - Section 2 reflects items the Work Group has identified but additional work is recommended.

The Day Program Work Group has identified seven types of developmental disability adult day programs funded by the Division of Developmental Disabilities:

  1. Developmental Training (DT)
  2. Regular Work/Sheltered Employment Workshop (RW/SW)
  3. Supported Employment (SEP)
  4. Vocational Development
  5. Adult Day Care
  6. At Home Day Program
  7. Other Day Program.

Of these programs, Medicaid matching funds (also known as Federal Financial Participation or FFP) are available for DT, SEP, At Home Day Program, and Adult Day Care through the Medicaid Waiver or, as in the case of DT for individuals residing in Intermediate Care Facilities for Developmental Disabilities (ICFs/DD) and DT for individuals residing in state-operated Developmental Centers (SODCs), FFP is available through the Medicaid State Plan. Except for the grant-funded Vocational Development program, these day programs are funded through a rate on a fee for service unit billing basis.

The Day Program Work Group initially discussed each of these adult day programs, before determining that it was not realistic to review such a broad range of programs all at the same time. Because the greatest utilization of day programs by far is in the Development Training program (see the chart below), the Work Group members agreed to defer the review of other day programs for the time being. In the interest of working quickly, the Work Group also chose to identify short and long-term recommendations most applicable to the Medicaid Waiver Developmental Training Program. However, it should be noted that the flat rate for Developmental Training, currently $10.39 per hour or $11,429 annually, is also applicable to Regular Work, At-Home Day Program, and Other Day Program and it is possible that much of the discussion and recommendations in this paper could be applicable to these, as well.

FY08 Day Program Full Time Individual Equivalent Utilization By Funding Type

Funding Type DT Regular Work SEP All Other
CILA 6,184 569 292 376
HBSS/DT Only 4,136 112 39 0
Purchase of Service 279 7 21 0
ICFs/DD & SODC 6,916 0 N/A 0
Total 17,515 688 352 376

Note 1: The Home-Based Support Services (HBSS) Program (type "H" has replaced Developmental Training Only funding type and figures are combined for purposes of this presentation.

Note 2: The figures do not represent the actual number of individuals served in these programs as many individuals may attend both DT and RW, for example, on a part-time basis and would be counted multiple times in each program.

Note 3: All Other Day Programs include At-Home Day Program and Other Day Program, which are only available to individuals enrolled in CILA, and All Other also includes Adult Day Care.

The Division of Developmental Disabilities Program Manual for FY2009 provides the following definitions for Developmental Training and Regular Work:

  1. Developmental Training

    "Developmental training (DT) is a program of day habilitation that focuses on the development of and enhancement of daily adaptive living skills and economic self-sufficiency. Typical activities should be functional and performed at the natural time and in the natural environment, properly sequenced, and be developmentally and age appropriate. Such activities include fine and gross motor development, attention span development, safety, problem solving, grooming, dressing skills, toileting, eating, communications, reduction of maladaptive behavior and promotion of adaptive behavior, quantitative skills, and capacity for independent living. Developmental training also enhances an individual's ability to engage in productive work activities through a focus on professional development, which includes such habilitation goals as cooperation, attendance, productive capacity, and task completion. DT is governed by 59 Ill. Admin. Code 119 (Minimum Standards for Certification of Developmental Training Programs). This program provides the opportunity to participate in productive work and to be compensated for that work in accordance with the Fair Labor Act of 1938 (29 U.S.C. 208)."

  2. Regular Work/Sheltered Employment

    "Regular Work/Sheltered Employment provides long-term employment in a sheltered environment for individuals whose functional levels require supervision but are not precluded from future movement into a Supported Employment position or a competitive employment position. Regular Work/Sheltered Employment provides general work supervision, including direction and on-the-job training in such areas as work expectations, work place behavior, and compliance to workplace safety standards, production and task completion. This program provides the opportunity to participate in productive work and to be compensated for that work in accordance with the Fair Labor Act of 1938 (29 U.S.C. 208)."

Background

Although day programs have existed in some form or another at least since the 1970's, Developmental Training services date back to the mid-1980's to early 1990's, when the Division of Developmental Disabilities made the decision to standardize rates and to encourage state grant-funded sheltered workshop providers to convert their programs into "habilitation" programs for individuals that would also qualify for federal Medicaid Waiver matching funds, i.e., FFP. The increased federal matching funds garnered were used to further expand community DT services, with "habilitation skills training" as the core service principle driving the newly restructured services.

In order to bill for the new DT services, Medicaid required a fee-for-service billing system. The method used to determine the new DT reimbursement rate was literally allocating the same sheltered workshop grant dollars to clients who were to be enrolled in the new DT "habilitation" services (i.e., average cost per capita reported to DDD in grant agency plans. Thus the rate structure supporting the new DT services was established as a fixed amount per eligible enrollee.

The programmatic conversion process was complicated by the fact that sheltered workshop programs were traditionally operated using a facility-based model with factory-level production and supervisory staff with high staff to worker ratios. Thus creation of day program services literally required modifying an industrial, sheltered work model (and building) staffed with production-oriented personnel with average staff to worker ratios of 1:20; to an education and training service model wherein instructor/trainers were instead to provide individualized daily living and self-care skills training (habilitation) services in most cases, in factory buildings, a daunting challenge at best. Many programs understandably made minimal operational changes as a result of the initial conversion, since there were minimal changes in the funding structure, staffing and credential requirements, or other system redesign initiatives. Now, years later, DT programs strive to meet the staffing ratios spelled out in Rule 119 and in the 89 Ill. Admin. Code 140.648 rules regarding DT reimbursement for individuals residing in ICFs/DD.

As will be discussed later in this paper, it is more than historical interest to note that the ICFs/DD program in the 1980's were funded and regulated as nursing home services governed by the Department of Public Aid (DPA), now Healthcare and Family Services. The ICFs/DD program was not under the administrative purview of the Division of Developmental Disabilities (then the Department of Mental Health and Developmental Disabilities, i.e., DMHDD). By the beginning of the 1990's, DPA had developed a structured DT rate methodology that, like its residential rate methodology, was based on the collection of individual functional assessment information and information regarding specialized support needs.

In 1994, the programmatic responsibilities for the ICFs/DD residential and DT programs were transferred to DMHDD. At this point and to today, the Medicaid Waiver DT rate and the ICFs/DD DT rates have co-existed as two distinct rates.

Findings

Fast-forwarding to 2009, more than two decades after the sheltered workshop to developmental training, many of the same issues experienced during the rapid creation of Medicaid Waiver DT program services in the 1980's still influence the program today, including but not limited to a lack of a defined rate structure and "flat rates" not commensurate with the level of need of the individuals receiving services and supports, particularly individuals with special needs,

In addition to these points, the Work Group has also identified programmatic rate-related issues regarding the different types of staff needed, staff education and training requirements, staff wages and fringe benefits, billing caps (115 hours per month and 1,100 hours annually), the number of days of operation, the geographic location of the program, and the importance that transportation funding plays in DT programs.

The Work Group members believe that a significant trend in public policy and individuals' and families' preferences during the last several years has been a change in the emphasis for day program services to be less building-based congregate care and support environments and more community integrated support and service models where persons served, and their families, choose how to allocate their available state funds.

Work Group members note that Home-Based Supports and Services (HBSS) funded by the Division of Developmental Disabilities are now the primary non-residential service choice available to families. Anecdotally, HBSS service providers report that approximately one-half of families have not chosen DT services to support their adult family member with disabilities, and further, that many of the remaining have chosen to purchase DT services on an ad hoc, drop-in basis (less than 5 days per week or fewer than five hours per day).

This trend is beneficial and provides more choices to individuals and families, but it is also challenging for the developmental services system, providers, and programs to adapt to provide necessary and desired services in a flexible manner. Service planning, staff scheduling and cost management have become both more difficult but also more necessary.

  • The Day Program Work Group's recommendations and findings are based upon member's discussions about these developmental training trends and issues, a review of the ICFs/DD DT rate methodology, and the work of the SAC Rate Committee's Transportation Work Group and the Wage and Fringe Benefits Work Group.
  • The Transportation Work Group's focus has been on day program transportation and the reader is directed to the Transportation Work Group's Interim Report available on the Division's web page, and in the discussion presented in Section 2, Additional Review and Research Recommendations of this paper.
  • The Day Program Work Group has also relied heavily on the efforts and products of the Wage and Fringe Benefits Work Group. The Wage and Fringe Benefits Work Group focused narrowly on the types of staff primarily utilized in the CILA model and has recommended the use of the Bureau of Labor Statistics (BLS) Wage Data on Standard Occupational Codes (SOC) hourly wage data. These May 2007 Illinois-specific average gross hourly wages (including overtime pay and shift differentials but excluding bonus or other add-on payments and also excluding fringe benefits) have been trended forward to yield the FY09 Projected Average Hourly Wage. The Direct Support Person (DSP) title uses the "Social and Human Service Assistants" SOC 21-1093 series at $14.59/Hour; the Qualified Mental Retardation Professional (QMRP) title uses the "Community and Social Service Occupations" SOC 21-0000 series at $22.32/Hour; and the Supervisor title uses the "All Community and Social Service Specialists Not Listed Separately" SOC 21-1099 series at $19.20/Hour. BLS also publishes SOC series for Registered Nurses (RNs), and for Licensed Practical Nurses (LPNs).
  • The Wage and Fringe Benefit Work Group has also recommended the utilization of the BLS Employer Costs for Employee Compensation from the June 2008 BLS NEWS for the Midwest Division, North Central Region (IL, IN, MI, OH, and WI) as the source for a fringe benefit information in recognition of current mandated benefits such as payroll taxes and other non-mandated benefits such as health and life insurance and retirement that are essential to attract and retain workers. The identified fringe benefit percentage is 29.43% to be used as a multiplier to the base wage.

OVERALL RECOMMENDATION

Based on the trends discussed earlier, the Work Group's overall recommendation is that the current design and service options as now defined in Developmental Training rules and regulations should be examined and expanded to include services that today's families and persons needing supports are seeking. Meanwhile, the Work Group is making specific Section 1 Recommendations in Section 1 that follow and the Work Group also recommends that it continue its efforts on the items appearing in the Section 2 Additional Review and Research Recommendations.

  1. RECOMMENDATIONS

    This Section 1 provides the Work Group's recommendations on items the Work Group has reviewed over the course of the past several months.

    1. Fund Waiver DT Rate "Parity" With ICFs/DD DT Rates

      Until such time as a rate methodology for the waiver-funded developmental training can be developed and evaluated (see a detailed discussion on this in the Additional Review and Research Recommendations Section), the Work Group is proposing a "parity" increase to the waiver DT rates to an ICFs/DD DT level as a short-term means of addressing that individuals in the Waiver who typically either live with their families or reside in their CILA are being served in developmental training programs right along with individuals who reside in an ICF/DD.

      One typical circumstance that clearly highlights this disparity issue is what becomes of the DT rate for an individual residing in an ICF/DD that has agreed to downsize. The individual continues to receive DT services from the same provider, yet the rate will typically be lower after the individual's funding switches to the Waiver.

      The following table illustrates a comparison of the FY08 and FY09 statewide average annualized Waiver DT and ICFs/DD DT rate:

      FY2008/2009 Day Program Annualized Rates By Funding Type
      Fiscal Year Waiver DT ICFs/DD DT
      2008 $11,360 $12,709
      2009 $11,429 $13,021
      • Note 1: The FY08 Waiver DT rate reflects the weighted average of 3 months at the 7/1/07 rate and 8 months after a 2.5% COLA on 3/1/08.
      • Note 2: The FY08 ICFs/DD DT rate reflects the weighted average of 3 months at the 7/1/07 rate and 9 months after a 2.5% COLA on 3/1/08.
      • Note 3: The Hourly Waiver DT rate is $10.39 for a maximum of 1,100 hours. The rate would become approximately $11.84.
      • Cost Estimate: The following tables present the estimated cost to increase the FY09 Waiver DT rates to the average FY09 ICFs/DD DT rates from the previous table, an increase per person per year of $1,592. The table also provides an estimate of the cost of a $500 incremental increase to the Waiver DT rate for perspective.
      Cost To Achieve FY09 "Parity" and Cost of Each $500 Incremental Increase
      FTE Persons Enrolled (FYO8) Waiver DT "Parity" Cost Each $500
      CILA 6,184 $9,844,681 $3,092,000
      Day Only 3,149 $5,013,082 $1,574,500
      HBSS 987 $1,571,265 $493,500
      Other POS 279 $444,157 $139,500
      Total 10,599 $16,873,184 $5,299,500

    2. Discussion

      In making this "parity" proposal, the Work Group notes that the cost impact reflects an across the board increase to the system. However, HBSS funding allotments are flat amounts that would not necessarily increase with the increased cost of the DT service an individual might be purchasing. Statutory changes in the HBSS funding limits might be one consideration.

      The Work Group also recognizes in making this recommendation that it is making a few arguable assumptions:

      1. Individuals funded in the Waiver are not, on average, functioning at an adaptive level either higher or lower than individuals in ICFs/DD settings.
      2. Individuals funded in the Waiver do not have, on average, medical needs or behavior needs that differ from those of individuals in ICFs/DD settings.
      3. Individuals funded in the Waiver are neither more nor less ambulatory, on average, than individuals in ICFs/DD settings.

        The difficulty in demonstrating that these assumptions are true to any large degree lies in the fact that there are not common or comparable assessment processes between the Waiver and ICFs/DD systems to say that the two populations are, in fact, the same.

        Indeed, this point of similarity was central to one consideration the Work Group had early on in its discussions that the Waiver DT rate-setting process could adopt the ICFs/DD DT rate methodology. However, the Work Group recognized rather immediately that, while the structure and components of the ICFs/DD DT rate model were perhaps reasonably reflective of the types of costs funded in a traditional DT program, individuals in the Waiver DT programs did not have the same type of data collected that is necessary to use the ICFs/DD DT rate model to calculate individualized rates for persons in the Waiver. Further discussion of this consideration is deferred to a presentation in the Additional Review and Research Recommendations in Section 2 of this paper.

  2. Additional Review and Research Recommendation

    1. Continue Work Group Review of Existing or New Rate Methodologies

      The Work Group identified that the only existing rate methodology for Developmental Training is the ICFs/DD DT rate methodology. The Work Group reviewed the origins of the ICFs/DD DT rate methodology to better understand its structure and potential for use in rate setting for the Waiver DT program.

      The ICFs/DD DT rate setting is based on a model that applies information collected and reviewed by the Illinois Department of Public Health (DPH) survey teams in the annual licensure and certification surveys of ICFs/DD facilities. The model is based upon the staffing and staff ratios from the DT Rule 119 and rule 140 described earlier.

      The DPH survey teams collect information on a Level of Function (LOF) measure, Specialized Care (medical/behavior) indicators, and individuals' need for special transportation. Each of these measures is described in the following paragraphs.

      The survey teams collect information on a Level of Function (LOF) measure that is based upon an individual's IQ using accepted standardized tests and the individual's functional skills and adaptive behaviors. Consideration is also given when cerebral palsy, seizure disorder, autism or another related condition is present. LOF scores are categorical: mild, moderate, severe/profound. DT Staffing ratios applicable to these are 1:10, 1:8, and 1:5, respectively. QMRP staff time is provided at a ratio of 1:30 for all persons.

      In addition to this basic staffing component, the DPH survey teams also collect information on Specialized Care, i.e., whether an individual has a medical or behavioral support need and whether the DT provider is providing and documenting supports provided. There are three (3) levels of these Specialized Care needs that vary by degree of support need and the DT rate model provides an additional amount of direct service support funding of 1/2 hour, 1 hour, or 2 hours per day. RN staff time is funded for individuals in the level 3 (highest need) of medical and sensory supports. A flat dollar amount is provided.

      Additional staff time is also included in the rate calculation for individuals whose survey data indicate they require assistance with transportation, i.e., assistance could range from continuous full or partial use of a wheelchair and a ramp or loading device to substantial assistance in balancing and weight-bearing movement. A flat dollar amount is provided.

      The ICFs/DD DT rate methodology distinguishes two geographic areas of the state and applies a multiplier to the sum of the above rate components of 1.2 for individuals served in DT programs in Cook, Kane, Lake, McHenry, and DuPage counties.

      To the result, an "agency component" for capital (building and fixed equipment), base transportation (vehicles and all operating costs associated with transportation of individuals to/from the DT program), and support (general administration and general services, such as housekeeping, utilities, etc.).

      As mentioned earlier, the Work Group considered applying this ICFs/DD DT rate methodology, however, the Work Group abandoned consideration of the ICFs/DD DT rate methodology for the time being because of the lack of common measures used to set the ICFs/DD DT rates. Future efforts to collect ICFs/DD style data for persons in the Waiver or to recalibrate the ICFs/DD DT rate methodology to use measures commonly (but not now universally) available in the Waiver could be reason to revisit this consideration or a future direction for the Work Group.

      The Work Group pursued an exploration of the potential for using either the ICAP or IQ scores, which are available at least for individuals in the Waiver who receive CILA supports. The Work Group wanted to evaluate whether the ICAP scores could be used as approximations or equivalents of the LOF categories. The Work Group examined DPH data on 4,402 individuals residing in ICFs/DD where all data elements were present for all individuals. The Work Group analyzed IQ scores, LOF categories, the Inventory of Client and Agency Planning (ICAP) scores, and an ICAP range category that was the same as the original (pre-1998) implementation of the CILA residential rate model's use of the ICAP to create three (3) levels of need based on ranges of ICAP scores: 1-39 (high need), 40-69 (moderate need), and 70 & above as low need.

      To examine this, the Work Group analyzed the correlation between these variables. The following table displays the correlation results obtained.

      Assessment Method Result
      ICAP & IQ Correlation 0.632946
      ICAP & IQ R-Squared 0.400621
      LOF & IQ Correlation 0.706722
      LOF & IQ R-Squared 0.499457
      LOF & ICAP Actual Score Correlation 0.775728
      LOF & ICAP Actual Score R-Squared 0.601754
      LOF & ICAP Category Correlation 0.704181
      LOF & ICAP Category R-Squared 0.495872

      Note: Significance testing was not done.

      As these results indicate, although the strongest relationship (r=.776) appears to be between an individual's LOF level and their ICAP score - an indication that there is positive correspondence or agreement between a mild/moderate/severe-profound categorization and an ICAP score - the R-Squared values, which is a statistic that describes the percentage of variation between two items that is explained by these two items taken together, the r2=.602 result for the LOF and ICAP Score indicates that there are other factors not taken into account that could be considered to explain variation in these scores. It is conjectured that at least one source of variation in all of these comparisons is "error", i.e., inconsistencies among the assessors and/or variation in the assessment instrument or process itself.

      In conclusion, the Work Group questioned that the basic input data of the LOF used in the ICFs/DD DT rate model information was not available on individuals in the Waiver (except perhaps for those individuals that have recently moved from an ICF/DD) and that the relationship of the ICAP to the LOF from these ICFs/DD data was not strong enough to make a "leap of faith" regarding their equivalencies.

      In addition, the ICFs/DD Specialized Care and ambulation indicators are not available for anyone in the Waiver. The Specialized Care Waiver counterpart measure is the Health Risk Screening Tool (HRST). The HRST is only available for CILA-funded individuals.

    2. Recommendations for a Developmental Training Rate Methodology

      The Work Group has discussed and identified several features that a Developmental Training rate methodology should include to provide a quality program at an adequate rate and is recommending the Workgroup continue working in the following areas:

      1. Develop Teacher/Instructor Positions in Developmental Training

        The Workgroup believes the specialized habilitation and training needs of individuals using DT services may warrant the consideration of Teachers and Instructors trained in planning, overseeing and providing specialized supports. The Work Group has discussed that a master's level special education staff position should be added to the base rate of DT services to improve the quality of DT instructional services. This belief is founded on the Work Group members' experiences with individualized service planning for at least some individuals. Educational credential requirements need to be upgraded for staff functioning as teacher-instructors. The Work Group is recommending its further consideration of the extent of the need for this type of specialized staff that are beyond the duties, training, and experience of current Direct Support Persons (DSP) and QMRP staff.

      2. Components of a DT Rate Methodology Should be Updated Annually

        The Work Group believes it is imperative that changing costs of providing DT services should be recognized. It proposes that elements of a rate methodology should rely on readily available and generally accepted wage, fringe benefit and other cost indices so they can be updated regularly or when funds are available to do so. The Work Group recommends the adoption of recommendations of the Wage and Fringe Benefits Workgroup to increase DSP, QMRP, and RN/LPN wages and fringes benefits using Department of Labor, Bureau of Labor Statistics wage and benefit data for social service positions in order to recruit and retain qualified personnel.

      3. Transportation for Day Programs Should Be Funded Separately

        Many Day Program Work Group members have also served on the Transportation Work Group and support the recommendations associated with the Transportation Work Group's findings. The reader is referred to the Transportation Work Group Report available at the Division's web page for the Statewide Advisory Council, Rate Committees.

      4. Additional Staff Time Allowance

        The current operations and funding of a typical Developmental Training program rely on service models and staff ratios that are facility-based and that do not support the increased staff needed for broader community access and skills development/learning to use community resources and activities. The Work Group recommends that the base staff to DT recipient ratio be increased to 1:3 for such planned services features in DT programs.

    3. Specialized Needs and Individualized Assessment Processes

      The Work Group has frequently discussed the need to have uniform, accurate, appropriate, reliable, and objective assessment tools and processes regarding identifying and addressing individualized needs through the rate.

      It is imperative that efforts are made to employ or construct or adapt diagnostic and assessment instruments that can be properly and objectively used to accurately and reliably assess or measure one's needs in the following areas and to determine funding the specialized supports discussed below.

      The reader is referred to the Statewide Advisory Council Rate Committee Interim Report for additional discussion regarding addressing specialized support needs including medical, behavioral, physical/personal care, ambulatory assistance, and alternative communication needs.

    4. Permit Medication Administration in Day Programs

      The Work Group supports the expansion of the concepts of "self-medication training" and medication administration in day programs. This would change and enhance the role of nursing personnel in day programs and be consistent with practices currently permitted in residential settings of 16 or fewer individuals.

    5. Modify the Current Waiver DT Monthly and Annual Billing Caps

      Currently the Waiver DT billing is limited to a cap of 1,100 annual hours and 115 monthly hours. The 1,100 hours is based on a five hour program day (not including transportation and lunch and rest breaks) for 220 days of operation. The Waiver DT rate of $11,429 is an annual rate that pays for 240 days of operation, the traditional number of days of operation of approximately 20 days on average per month for 12 months and that is the basis for the monthly payments for ICFs/DD DT reimbursement. The billing of 220 days per 1,100 hours accommodates non-attendance as an absence factor, allowing 20 days per 100 hours per year. The 115 monthly hours is designed to dually accommodate program day lengths of more than 5 hours and/or more than 20 days per month. In addition, it also affords a form of protection when an individual changes DT provider at some point in a year by assuring that the individual's 1,100 annual hours are not exceeded disproportionately by a former provider.

      Several Work Group members reported that many providers operate DT program services 5 1/2 to 6 hours and that their annual days of operation, which vary by the average "work days" in any given month can vary from fewer than 240 days up to as many as 265. In addition, day program closures for vacation for individuals and for agency staff are a somewhat common occurrence. An individual's absences for a large part of a given month may produce a situation where the maximum monthly hours cannot be billed in that month, but over a period of a year, the actual amount of services provided, could exceed the monthly or annual limits and limit the program's reimbursement.

      In should also be noted that common practice among HBSS individuals and families desiring to spread the annual DT funding evenly across their monthly HBSS allotments and across a full twelve (12) months and 1,100 limits their attendance to an average of approximately 91.6 hours per month (1,100/12=91.6). This not only limits their monthly attendance but Workgroup members' experience is that individuals attendance on any given day or for any amount of time on a given day is sporadic, which makes it difficult in scheduling staff to accommodate an unpredictable attendance pattern. Providers have worked with HBSS individuals and families to schedule regular attendance to some degree of success.

      Briefly, the ICFs/DD DT billing should be noted. The ICFs/DD DT billing is at a monthly rate. Billing is based on a percentage basis of planned attendance versus planned scheduled days of operation. In the month following the service month, each provider's billing statement reports both the scheduled days of operation and the planned percentage attendance for each individual. For example, if an individual is planned to attend 100% of all 20 days of scheduled operation, 100% of the monthly rate is paid to the provider. Thus, regardless of the number of days of operation in a given month, the monthly rate does not vary. If an individual is absent for one or more days, there is no offset or reduction in the monthly payment. When an individual's actual attendance routinely varies from 100%, perhaps because, for a given month or across the board, the individual is a part-time attendee (i.e., they are scheduled to attend only three of five days per week or for only three hours of the five-hour day, the scheduled percentage reported on the billing is adjusted to 60%). The monthly rate payment for this person is then calculated at 60%. If a person will be temporarily scheduled for less than full-time in a given month because of an illness or injury or other reason, the provider is obligated to report an adjusted scheduled percentage. If the temporary scheduling resumes full-time or to some other percentage attendance level, the post-service monthly billing can be modified to reflect what the actual planned scheduled attendance percentage was to be. This method is a variation on the problems of how to budget available funding and allocate it according to a more predictable staffing pattern.

      The Work Group believes that the lack of standardized days of operation, the length of the program day, and sometimes sporadic attendance confound an efficient utilization of the Division's available Waiver DT funding for individuals, but the Workgroup has been unable to identify a more equitable means of means of billing for services. Consensus was not reached on a solution to this issue.

      The Work Group does encourage continued discussion of billing methods in conjunction with discussion about individualized DT rates and strongly supports the use of a single, common billing, payment, and Medicaid FFP claiming system across all types of DT funding.

    6. Looking to the Future - DT/Day Program Design

      A case could be made that there are now three different groups of individuals utilizing and benefiting from day program services.

      First are those who live in residential programs, primarily CILAs and ICFDDs, who attend day program programs very regularly, some due to regulations requiring them to attend a program outside the facility where they live.

      A second group utilizing day program services are those who live at home with family and have attended day program or sheltered work services on a relatively regular basis for decades (day program is the only state-funded service they currently receive).

      The third group is the newest and the wave of the future - those who receive HBSS funding. About half who reportedly do not choose day program services at all, and the other half who reportedly choose to attend less than full time on an ad hoc basis.

      It is unclear whether the reasons for these choices are due to the desire for less traditional, more community based services or other reasons.

    7. Over the next decade, as more people with disabilities, their families and agencies providing support services choose to move towards less facility-based service models, day program concepts should be modified, adapted, and expanded to support different choices. Some community agencies may already use some variations of such service models and others may be considering taking steps towards such transitions.

      Alternatives to current day programs might include the following:

      1. Day program centers may transition to Neighborhood Support Centers where no more than 30 persons gather from time to time for social and recreational purposes (start and end point of day; support staff office, etc.).
      2. Day program service locations may increasingly locate in store fronts, local churches, libraries, recreation centers, restaurants, shopping malls, community centers, senior centers etc., close to where the person receiving services lives.
      3. Support staff's role may increasingly become facilitating inclusion of persons served into their neighborhood and developing community partnerships to facilitate his or her inclusion.

      System change design will be needed to encourage and create these new service options and opportunities. Rate methodology and regulatory changes for new services will be needed.