Iowa Coalition for Integrated Employment

3.1Coalition building

The ICIE project began with a “Core Team” comprised of representatives from the four required agencies (Iowa Developmental Disabilities Council (DD Council), Iowa Vocational Rehabilitation Services (IVRS), Department of Education (IDE), and Department of Human Services (DHS)) that signed onto the Memorandum of Agreement required by the proposal. These four agencies had been previously engaged in the Governance Group. In addition to these four, representatives from former and existing projects were invited to join the Core Team representing Medicaid, the Employer Disability Resource Network (EDRN), community rehabilitation providers (CRPs), and the Olmstead Consumer Task Force. The functions of the Core Team were to: 1) Ensure grant function, 2) Clarify policy/practice (short term implementation), 3) Facilitate long-term systems change & improvement, and 4) Grow a coalition of stakeholders to shape the work.

The Core Team strategically identified a list of people who were sent an invitation to attend the first meeting of the Coalition. Consideration was given to the diversity of geography and experience. The Core Team also sought balance between state agency staff, family members, individuals with disabilities and community service providers as well as between administrators and direct service staff. Preparing the list came easily because of the previous number of individuals attending employment-related stakeholder and input meetings. Those who attended the first Coalition meeting were asked if there were others who should be attending and were asked to reach out to them.

The Coalition grew from 49 members (2012) to 243 diverse stakeholders (2016). Stakeholders included Iowans with disabilities, family members, community rehabilitation providers, case managers, State Agency representatives, Managed Care Organizations, and educators. Growth of the Coalition was largely due to an inclusive and engaging culture. People learned of the Coalition from those already attending, as well as through presentations about the Coalition and through their attendance at other meetings or conferences where the Coalition’s work was discussed. Those interested were welcomed, included and put to work. Some expressed concerns that 243 people were too many to really function as a coalition. However, there was enough work that people could direct their energies to the pieces that were of the most interest or best used their skills and experience. As a result, work groups were established as needed, and targeted conference calls and smaller focused meetings, separate from the Coalition Meetings, were held to address specific deliverables associated with the ICIE project. The full Coalition met quarterly to review implementation, monitor and evaluate activities, learn about specific topics and make connections between segments of the work, and to grow a sustainable advocacy force dedicated to long-term systems change. During Coalition Meetings, members also heard from specific stakeholder panels such as individuals with IDD, educators, and family members about their interests, needs and roles in CIE.

During the first meeting of the Coalition, facilitators were asked, “Are you trying to close sheltered workshops?.” An important strategy for engaging stakeholders in the Coalition was to honor the history and work of those who provide case management and employment, and to refrain from any mention of closing facilities. Instead, conversations focused on how to build on previous work to transform and extend the continuum of services to include more integrated, community-based supported employment service options. Coalition meetings provided an opportunity to share information about research and best practices in employment, as well as to understand the implications of emerging Federal legislation, regulations and guidance on practice and expectations in Iowa.

Engaging people in productive and lasting systems change requires that stakeholders see that they are welcome at the table and that their concerns, barriers, observations, experiences and talents are recognized. People who were advocating for the closure of “sheltered workshops” caused those working in or using the facilities (staff, clients, and families) to dig in their heels and strongly advocate against closure. However, very few found fault with expanding available employment services options to increase opportunities for skill building, trying out different environments and tasks, and pursuing interests. That’s the message the Core Team consistently asked the coalition members to use. The Core Team intentionally worked to ensure that the Coalition meetings were respectful of all opinions and experience. Discussion of different views led to understanding, relationship building and, ultimately, reaching consensus on solutions to address barriers.

However careful the Core Team was with their language, there were members of the Coalition who were not as careful and probably but inadvertently offended some of the providers. The Core Team response was to ask the providers to give a history of the concept of the facility-based services. Two representative providers described the historical context in which they had been working to provide employment services. They made two points that seemed to resonate with the audience: 1) they are doing the best they can with the information they’ve received and, 2) they are providing the services the system reimburses them to provide.

The Core Team communicated clear expectations and modeled trust and respect for individuals and opinions. It worked to build purposeful relationships between diverse stakeholders and foster collaboration. Coalition members acknowledged the team’s culture and also reported: 1) there is a shared vision for change; 2) opinions and ideas are valued; and 3) engagement is worthwhile, meaningful and contributes to improving Iowa’s system.

The Coalition was routinely asked for formal and informal feedback that helped shape the work and the focus of Coalition meetings. A survey of members during the 4th year of the project found that participants experienced positive changes in knowledge (80%), attitudes (78%), skills (61%), actions (74%), beliefs (61%) and whether their opinions were valued (100%). The fact that 100% of the respondents said they felt their opinions were valued was celebrated by the Core Team as having accomplished an important milestone in developing an effective and collaborative coalition.

3.2Leadership and oversight of coalition efforts

A key element to Iowa’s successful engagement of a large Coalition for far reaching statewide systems change was the use of independent contract staff who served as the backbone of the project. Without the prior allegiance to any one entity, the contract staff came to the project without preconceived notions of the role and strengths of the various entities engaged. They asked questions that otherwise might not have been asked by staff with previous experience and relationships. Staff further supported the project by providing strategic coherence between pieces of the work. Responsibilities of contract staff that contributed included:

Another key element was the fluid leadership assumed by Coalition Members who took action including volunteering to pilot solutions, serving on work groups, mentoring others, taking initiative and engaging in conversations to seek out solutions to barriers, speaking to legislators, engaging in conversations at the community level and challenging one another on employment outcomes for individuals served. This shared leadership also extended to the State Agencies involved, as agency representatives stepped up to facilitate groups tasked to complete work related to the agencies’ realm of responsibility. Examples include leaders from the Department of Education on the Model Education Transition Sites pilot project; IVRS on funding and services questions; Department of Human Services on reviewing the Administrative Rules. In addition, the Iowa Developmental Disabilities Council took the lead with policy and public awareness activities for National Disability Employment Awareness Month activities such as creating and disseminating videos of individuals talking about their work and issuing press releases and proclamations.

Iowa was also awarded an Employment First State Mentoring Leadership Project (EFSMLP) from the U.S. Department of Labor’s Office of Disability Employment Policy (ODEP) which had similar goals and objectives related to increasing employment services, provider capacity and employment services redesign. IVRS was the lead agency for that project. EFSLMP and ICIE leadership engaged in early planning to determine how to eliminate duplication and use resources collaboratively to meet mutual objectives of the two projects. Shared leadership emerged as a key strategy as members of the EFSMLP project team were on the Coalition, and Coalition Core Team members served on the EFSMLP team. The ICIE project originally planned to implement three pilot projects with CRPs. However, through a joint effort, the number of pilots increased to six. The availability of Subject Matter Experts (SMEs) through EFSMLP expanded the opportunities for training and technical assistance offered to the CRPs engaged in the pilots and, eventually, to a larger group of providers interested in transforming their services and programs to be more community-based.

3.3Informing employment services redesign

The strength of Iowa’s approach to redesigning employment services was the strong cross-agency and stakeholder collaboration. The collective leadership of the EFSMLP, ICIE, and SELN efforts and the commitment of each project’s leadership to work together to leverage knowledge, resources, and strategies without duplicating efforts made each project stronger and led to greater overall outcomes for the state.

In 2013, the Department of Human Services entered into a stakeholder engagement process with prevocational and supported employment stakeholders to redesign the HCBS Prevocational and Supported Employment services. This Employment Services Redesign was intended to bring HCBS prevocational and employment services into compliance with the definitions and service structure provided by the Centers for Medicare and Medicaid Services (CMS) in their 2011 bulletin and the 2015 1915(c) Technical Guide. The ICIE contribution to this effort began with its commitment to share resources with EFSMLP to increase the number of community rehabilitation provider pilot sites from three to six. The purpose of the pilots was to increase the capacity of providers to prepare, place and support individuals with intellectual and developmental disabilities (IDD) in integrated, community-based employment settings. The strategy used was to introduce customized employment as a best practice, begin to explore how to implement the components of the practice, and ask providers to collect implementation data. Each of the pilot sites was asked to identify people with IDD who had previously been deemed “unemployable” to be the targets for customized employment services. Site staff then participated in a three-day workshop and received coaching from an EFLMP subject matter expert (SME). Pilot sites also had individualized monthly conference calls and site visits with the SME for on-going training and technical assistance.

The availability of the SME benefitted provider staff. The SME modeled components of Customized Employment through hands-on field experience with job seekers. The SME could observe the job seeker and subsequently had a frame of reference when provider staff called to problem solve when they got stuck along the way. Providers experienced success quickly, with 14 of the original 30 targeted job seekers gaining employment within the first year.

The pilots were able to use a combination of funding (e.g., HCBS Waiver, IVRS and county dollars) to support some of the components of customized employment. These projects helped identify gaps in funding services and provided information to IVRS and Medicaid to inform necessary rate restructuring. Pilot sites reported that funding for the discovery services in customized employment was not available through the “traditional” IVRS reimbursement structure. That was resolved when IVRS added a new Discovery service code to their menu of services. Pilot site reports of time and cost data demonstrated where staff was investing time in service delivery, thus informing IVRS and Medicaid of the need to better align service options with funding. Findings from pilot projects fed into work by the SELN to assess Iowa’s Medicaid funding structure and consider alternative structures to support integrated employment services. Guidance documents prepared by SELN provided several key assumptions for Iowa to consider when rebalancing the rates. Leveraging ICIE resources, those key assumptions were shared in public community forums across the state to increase awareness of the intent to rebalance Iowa’s employment service system to support integrated community employment and to gather feedback on the assumptions. During these community forums, participants were invited to apply to participate on the Employment Services Redesign workgroup. This workgroup included representatives of CRPs from large and small communities across the state, case managers, family members, IVRS, Medicaid, and Iowa’s Division of Mental Health & Disability Services (MHDS) and the Department of Education. EFSMLP resources allowed for the SME to facilitate the Redesign Workgroup and, eventually, to draft recommendations. Between workgroup meetings, those ICIE members most interested in funding and policy met to review drafts and provide feedback. Multiple documents and resources were also made available to the public including individuals with disabilities and family members. Recommendations for employment service definitions, provider requirements, staff qualifications, staff training, reimbursement methodologies and a funding transition model were submitted to the Iowa Department of Human Services (DHS) in December of 2013.

As time elapsed with no response or follow-up from DHS, many of those who were engaged and supportive of the recommendations became frustrated and wrote to DHS staff asking for updates. DHS was most responsive to those inquiries by family members and, as a result, began to work with SMEs from the EFSMLP to draft Administrative Rules based on the recommendations submitted. Once Administrative Rules were drafted, the process appeared to stall again. It wasn’t until family members spoke with their legislators, who then asked questions of DHS, that the process began moving forward again. The Medicaid HCBS Employment Service Administrative Rules were finally adopted in May 2016.

The new Administrative Rules: 1) revise service definitions to match the Centers for Medicaid and Medicare Services (CMS) Bulletin (2011) and 1915(c) Waiver Technical Guide (2015), 2) change reimbursement rules including the fee schedule and the definition of billable activities to allow reimbursement for supports provided “on behalf of” and not in the presence of an individual, 3) redistribute some Medicaid resources to strengthen employment rates, 4) influence an increase in the array and quality of individual employment supports/services available, 5) align DHS and IVRS policy and funding, and 6) establish a monthly rate structure for Long Term Job Coaching Tiers that encourage “fading” over time, in favor of natural supports.

3.4Developing an outcome measurement system

The Governance Group had consistently discussed the barriers to creating a statewide employment outcome data collection system. Barriers included variances in data collected, different definitions of employment across agencies, disparate populations for whom outcome data was reported, as well as incompatibility of data systems. The Iowa Medicaid Infrastructure Grant (MIG) intended to support the development of an outcome measurement system related to CIE for individuals with disabilities. The ICIE Core Team coordinated with staff who had worked on the MIG, and with SELN, to review existing core employment outcome measures and identify sources of outcome data for Iowans receiving Medicaid funded long term supports and services. The ICIE Core Team, MIG staff and SELN consultants had multiple conversations and facilitated a full day meeting with diverse stakeholders who provided recommendations and feedback to determine meaningful outcome measures. Because of that meeting, three core outcome variables were recommended to be the basis for employment data measurement in Iowa: work status, hours worked and wages. The ICIE Core Team reviewed and adopted these three performance measures to describe individual outcomes as a measure of system performance to be used in the course of the PIE. Ultimately, the Outcome and Performance Measures Workgroup of the MHDS Redesign adopted these measures as well to assess MHDS funded services statewide.

ICIE then sought and received MHDS approval for staff support to pilot and test a data collection method for gathering individual level information on outcomes of employment related services provided with public funds. A secondary goal was to obtain some baseline data which would be useful to gauge the impact of the employment systems change work in process. In addition, the pilot would collect process information from providers so that feedback could be used to develop a convenient data collection and reporting system to gather meaningful data moving forward.

Nineteen CRPs from 29 locations, and representing 12 of the 14 MHDS Regions across Iowa, participated in the data collection pilot. Providers, representing small and large organizations, were recruited through individual contacts, meetings with ICIE staff, and through consultation with MHDS Regional CEOs. They represented all parts of the state, including both urban and rural locations. An unduplicated total of 2,104 persons received services during a two-week period. The number of hours worked, the wages earned and the services setting (individual, group or facility) was collected and reported on an individual basis. Those receiving job development services were also reported. Many people received more than one service during the reporting period.

Providers reported they did not view the data collection process and tool to be burdensome. Additionally, they reported the information was useful and expressed willingness to collect the data on an ongoing basis. Two MHDS Regions adopted the data collection tool and process for their ongoing required monthly reporting by CRPs.

3.5Pilot demonstrations: Model Employment Transition Sites (METS)

The Model Employment Transition Sites (METS) were pilot projects designed to determine services, supports and procedures that lead to effective ongoing preparation, placement and support services for students beginning early in high school and resulting in employment outcomes. The Department of Education and IVRS staff collaborated on the METS to determine selection criteria for pilot sites and provide training, technical assistance, oversight and reporting. The project began with a review of the literature completed by TransCen (2012) for the Iowa Department of Education to determine essential elements around which to build the framework for effective employment preparation programs. The elements included:

The staff reviewed data to determine those school districts that, based on the data, appeared to be more effectively transitioning students to employment and/or post-secondary education. Data points were pulled from IVRS and Department of Education systems level data, including Indicator 14 data and IVRS Student Status Reports, as well as individual IEPs and IVRS Case Reviews. The higher performing school districts were asked whether they were interested in participating in the pilot project. Five volunteered and participated in team reviews of the data with the Department of Education and IVRS staff. As staff and local district teams reviewed and discussed initial data they came to the realization that their current approach was not yielding the desired employment outcomes for students. This led to discussions about what each of the districts needed/wanted to do to improve outcomes, and each developed annual plans to pursue them. Districts were not required to address all four of the essential elements in their annual plans. Instead each determined which area(s) on which to focus.