Hi Kristen,

We have state statute but I wouldn’t say best practices on this topic. Caregivers must be 18, go through training provided and at the discretion of the employer, and pass a criminal background check. The level of rigor compared with the compensation for the types of supports outlined in your state does seem like an unusually high bar.

 

We have a fully self-directed long-term care option in WI that nearly 15,000 participate in. Those in rural areas in particular appreciate the option of hiring their own workers: as you say, drawing often from family and neighborhood connections because of the lack of agencies/providers. The national labor demographics are showing the provider shortage will only intensify in the next 10 years, particularly as the need for workers is going up. We are doing some work with other groups to further examine the automatic exclusion of people with felony records, particularly when the arrest was for a non-violent crime and for those where a lot of time has transpired. We have gotten feedback particularly from the African American and Native American communities that they often go without care because they cannot find workers, yet have family members or others in their networks who would be reliable caregivers but can’t pass the background check. We also have the highest incarceration rate for African Americans in the country and a high number of people who were incarcerated without going to trial. This disproportionately affects these communities around the hiring of friends and neighbors.

 

Beth

 

 

Hello Executive Directors and NACDD Community,

 

My apologies for this long email inquiry.  I am seeking input on best practices on requirements for independent (self-directed) providers who provide HCBS to individuals with developmental disabilities.

 

Nebraska Background:

 

In 2016 the state of Nebraska applied for two new HCBS developmental disability services waivers.  CMS has approved these new waivers, and recently all of the waiver participants have transitioned to them.  A key piece to the waiver renewal process included Nebraska “unbundling” services.  Another controversial (within the advocacy community and with families) was the new requirements for independent, non-specialized providers.

 

In the past decade there has been an expansion of the Community Support Services (self-directed) options for individuals who want services in their own communities or choices other than the available providers in their region. Advocates worked hard to bring participant self-direction to our state to afford participants more freedom and responsibility in the management and delivery of their services.

 

Many families, especially families and individuals with developmental disabilities in rural area, have benefited greatly from the independent provider services. However, new requirements for independent providers as noted in the new waivers and within the new state administrative regulations have upset some self-advocates and family members.  They consider the new requirements burdensome and fear that the new requirements make access to hiring their own staff even more difficult in areas of the state where there are shortages of direct support professionals.

 

Prior to the new requirements, independent providers had to meet the standards in state regulations which included completing and passing a provider background check which includes both criminal and abuse registry records.  Independent Providers also had to be at least 19 years old. 

 

The new requirements for Independent Providers area as follows:

 

All independent providers for the Developmental Disabilities Waiver services must be 19 years of age or older to provide services.

The following are required of Independent Providers to provide Supported Employment Individual, Supported Employment Follow-Along, Adult Companion Service, Consultative Assessment Service, and Prevocational Service:

1) Complete all provider enrollment requirements;

2) Have necessary education and experience, and provide evidence upon request:

• Have a Bachelor’s degree or equivalent coursework/training in: education, psychology, social work, sociology, human services, or a related field; OR
• Have four or more years of professional experience in the provision of habilitative services for persons with intellectual or other developmental disabilities (IDD), or in habilitative program writing and program data collection/analysis, or four or more years of life experience in teaching and supporting an individual with IDD; OR
• Have any combination of education and experience identified above equaling four years or more;

3) Have training in the following areas, and provide evidence of current certificate of completion from an accredited source, when applicable, or upon request:

• Abuse, neglect, and exploitation and state law reporting requirements and prevention;
• Cardiopulmonary resuscitation; and
• Basic first aid;

 

4) Be age 19 or older and authorized to work in the United States;

5) Not be a legally responsible individual or guardian; and

6) Not be an employee of DHHS;

7) Possess a valid driver’s license and insurance as required by Nebraska law, if transportation is provided.

In addition to the coursework/training and experience requirement, families and self-advocates do not like that a person who want to provide independent provider services must make arrangements to register, pay for, take, and complete a CPR and First Aid Course.  The independent provider is responsible to pay for this training out of their own pocket.

 

When asked, DD Division leadership told advocates that these qualifications were increased because the new service definitions (that were unbundled) have a habilitative component.   The previous waivers’ service definition that most independent providers fell under was a non-habilitative service that bundled a variety of services under one service definition.  Within the new waivers, services have been unbundled from this service definition, and all but one code of the proposed service definitions include a habilitative component. DD Division leadership have increased the independent provider qualifications to ensure that the habilitative plan and goals are met. (The DD Division has set programmatic expectations for the independent provider to have the skills to write and implement a habilitation plan as reflected in these higher qualifications.)  The DD Division leadership also stated that they want to strengthen safety and ensure a well-qualified work force for those who select independent providers.  We were told that the state based the new requirements based on “best practices” within other states.

 

The Council provided public comment that these elevated qualifications would make it very difficult for families who use self-directed services to find qualified staff, especially in rural areas.  Many families and individuals draw from their personal networks of family members not living in the household - friends, neighbors, teachers, paraprofessional/teacher’s aides, church members, and local college students in order to select independent providers for participant-directed services.  We went on record that requiring an independent provider to have a bachelor’s degree or 4 years’ experience would impact the ability of families to successfully use self-directed services, especially in rural areas of the state.   We also shared concern about the burden for independent providers to become CPR and first aid certified at their own expense.  Rather, we suggested that the state provide free training for certification for those wanting to become independent providers (and the specialized providers do not like this suggestion). 

 

Members of the Nebraska Association of Service Providers (NASP), a state-wide membership association of community organizations that provide supports to people with disabilities, have gone on record multiple times in support of the elevated qualifications for the independent providers.  NSAP providers are considered specialized providers within the state and must go through a rigorous process to be certified. In addition, all residential settings of four or more individuals must be licensed by the Department of Public Health.  Many specialized providers hire and train direct support professionals who don’t meet the elevated requirements for independent providers (4 year degree, etc.).  Additionally, their employees receive the required CPR and First Aid certification training as part of the employee orientation. NASP members claim that they want heightened requirements for independent providers in order to protect the health and safety of the vulnerable DD population. Specialized providers have a concern that independent providers deliver the services with less checks from the state, compared to their requirements.

 

It is important to note that many advocates think that the specialized providers are concerned about the increased competition for HCBS waiver services business, and perceive their stance as self-preserving.

 

I want the Council to balance the considerations from the specialized providers (i.e. protection and safety) with family concerns of access to independent provider services as this debate continues.  Would you please consider sharing examples of best practices and requirements used in your states for independent providers?  Thank you!