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Supported Employment Quality Improvement Study

Intellectual and Developmental Disabilities Supported Employment Services: Analysis of Cost of Services, Personal

Outcomes, and Support Coordinator Performance

Submitted to the Georgia Department of Behavioral Health and Developmental

Disabilities

Prepared by Qlarant, Inc.

The Georgia Collaborative Administrative Services Organization

DBHDD Quality Improvement Study Intellectual and Developmental Disabilities Supported Employment Services: Analysis of Cost of Services, Personal Outcomes and Support Coordinator Performance

The Georgia Collaborative ASO/ Qlarant Quality Solutions September 10, 2019 2

Abstract

Background: Supported Employment services assist individuals with intellectual and

developmental disabilities (IDD) to work in an integrated community environment. Research

has shown the positive financial impact of Supported Employment, as well as the benefits of

improved community integration and natural supports through integrated employment.

The Department of Behavioral Health and Developmental Disabilities (DBHDD) is committed to

supporting individuals with IDD to enhance community integration through services that

support employment in the community. This commitment is shown through DBHDD’s

membership in the Supported Employment Leadership Network (SELN) and recent

collaboration with the Georgia Vocational Rehabilitation Agency (GVRA). DBHDD has also

contracted with WISE, a Washington State consulting agency, to provide technical assistance to

stakeholders on community employment.1 This study is an additional effort to explore Georgia

specific evidence to help guide quality improvement initiatives that will increase the use of

supported employment for individuals receiving home and community based services in

Georgia.

Objective: The purpose of this study is to explore the potential impact of Supported

Employment on the average cost of Home and Community Based Services (HCBS); on personal

outcomes for people with intellectual and developmental disabilities (IDD) receiving those

services; and on different aspects of Support Coordination that may be associated with the

individual’s likelihood of receiving Supported Employment.

Data and Methods: The analyses were conducted using data from three fiscal years (July 2015

through June 2018) and data from three different sources: Medicaid Claims data from GAMMIS

(Georgia Medicare and Medicaid Information System), demographic data from the DBHDD

Client Information System (CIS) and quality data from the Person Centered Review process,

completed onsite by Qlarant reviewers.

Results: Claims data analysis indicated the average annual cost of services received by

individuals through the HCBS waivers was approximately $2,000 less for people who had

Supported Employment compared to people who did not receive the service. This cost benefit

is coupled with improved individual outcomes for people with Supported Employment,

specifically outcomes related to Community Life and Safety. Individuals were more likely to

receive Supported Employment when there was documented evidence of Support Coordinator

1 For further information on WISE, go to the following link: https://www.gowise.org/



efforts related to informed choices about community integration and employment, and how

they addressed personal strengths and preferences for people receiving services.

Conclusion: Having Supported Employment appears to reduce the cost of services and improve

outcomes for individuals receiving services. In addition, there are specific areas for Support

Coordination that can be targeted to help improve the likelihood of receiving Supported

Employment. These and other findings are discussed in detail, with recommendations provided.

Background

Georgia’s Department of Behavioral Health and Developmental Disabilities (DBHDD) oversees

services provided through state funds and Medicaid Home and Community-Based Services

(HCBS) waivers to individuals with intellectual and developmental disabilities (IDD). The

Georgia Collaborative Administrative Services Organization (the Collaborative) has been under

contract with DBHDD since July 2015 and is comprised of three partner companies: Beacon

Health Options, Qlarant and Behavioral Health Link. One purpose of the Collaborative is to

evaluate the quality of services and support quality improvement of the service delivery

systems provided to individuals receiving services through state funds and the HCBS New

Options Wavier (NOW) or Comprehensive Supports (COMP) waiver.

As part of the Collaborative’s contract, Qlarant Quality Assessors conduct 480 Person Centered

Reviews (PCR) each year to determine the quality of life and effectiveness of the service

delivery system from the perspective of individuals served. The PCR utilizes a representative

sample of adults from across Georgia who either receive services through the NOW or COMP

waiver or through state funded services. Each individual participates in an interview process

that includes the National Core Indicators (NCI) In-Person Survey and the Individual Interview

(II) - an additional interview developed by Qlarant, in collaboration with DBHDD.2 Records are

reviewed for all services the individual receives, per provider, including Support Coordination.3

Staff who provide each service and the Support Coordinator are interviewed and an onsite

observation is completed at the day program and licensed residential home, as applicable. The

record reviews, interviews and observations provide in-depth insight into the outcomes present

in the individual’s life.

2 For more information, see http://www2.hsri.org/nci/ about the development and implementation of the NCI surveys. See http://www.dfmc-georgia.org/ for the additional tools and review components for the PCR review process and more information about the II and all other Delmarva tools and review procedures. 3 Support Coordination Services identify, coordinate, and oversee the delivery of services and supports to enhance the health, safety, and general well-being of NOW and COMP waiver participants within the context of the person's goals toward maximum independence. For more information, see DBHDD’s website at https://dbhdd.georgia.gov/support-coordination.

http://www2.hsri.org/nci/

http://www.dfmc-georgia.org/

https://dbhdd.georgia.gov/support-coordination



Georgia’s DBHDD practices an ongoing commitment to quality improvement in ensuring

individuals are receiving services as intended and person centered practices are infused

throughout the system. To that end, DBHDD has worked with the Collaborative to develop a

quality improvement study with a focus on Supported Employment. The study presents

analyses on the average cost of the service compared to other services, the effects on personal

outcomes for individuals receiving Supported Employment through the waivers, and the

potential impact of Support Coordination’s performance on the likelihood of receiving

Supported Employment services.

Purpose

Supported Employment is a service offered to individuals with IDD to assist them to work

successfully in an integrated community environment. It is generally expected Supported

Employment positions will include competitive wages as well as provide employees with the

opportunity to receive company benefits realized by all employees in the organization. Carli

Friedman, Council on Quality and Leadership (CQL) Director of Technical Assistance and Data

Analysis, analyzed 110 HCBS waivers from 45 states and the District of Columbia. This

information was gathered from the Centers for Medicare and Medicaid Services (CMS) to

determine utilization and expenditures of Supported Employment services for people with IDD.

It was reported that compared with other settings, the benefits of Supported Employment

include higher quality of life, and more engagement with people who do not have a disability

(Jahoda et la., 2008; Kilsky and Breyer, 1996; Verdugo et al., 2005).4 In addition, Friedman

found that approximately three quarters of the HCBS waivers offered Supported Employment

with an annual average cost of $6,700 per individual.

Paul Wehman, et. al. (2014) found that Supported Employment increased employment rates,

particularly among youth who were Social Security beneficiaries, special education students,

4 Friedman, Carli. Waiver Funding for Work: Supported Employment for People with IDD; posted 2/28/2017; Jahoda, A., Kemp, J., Riddell, S., & Banks, P., Feelings about work: A review of the socio-emotional impact of supported employment on people with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities, 21(1), 1-18 (2008); Kilsby, M., & Beyer, S., Engagement and interaction: A comparison between supported employment and day service provision, Journal of Intellectual Disability Research, 40(4), 348-357 (1996); and, Verdugo, M., Jordan de Urries, F., Jenaro, C., Caballo, C., & Crespo, M., Quality of life of workers with an intellectual disability in supported employment, Journal of Applied Research in Intellectual Disabilities, 19(4), 309-316 (2006).



and high school graduates with intellectual disabilities or autism.5 Previous research has also

shown the cost benefits for individuals with disabilities who receive Supported Employment

services. In 15 of 18 studies reviewed, Cimera (2000) found Supported Employment was “cost-

efficient” and concluded the “financial rewards (e.g., wages earned) of being employed via

Supported Employment exceeded the resulting costs (e.g., reduced government subsidies).”

Specifically, most studies found that supported employees earned more wages in the

community than in sheltered workshops or other alternative programs (e.g., developmental

training).6 Cimera (2008) later compared two groups of individuals receiving Supported

Employment: one with people who participated in sheltered workshops and one with people

who did not participate in sheltered workshops. Groups were matched on diagnosis, secondary

conditions and gender. Individuals in both groups were equally likely to be employed; however,

supported employees not participating in sheltered workshop activities earned significantly

higher wages, worked more hours, and were less costly to serve ($4,542.65 versus $7,894.63).7

Kregel, et. al. (1989) found that regardless of primary disability, people receiving Supported

Employment saw increased hourly wages, a greater number of hours worked, increased overall

earnings and better levels of job integration. Further, their findings indicated the individual

placement model generated superior employment outcomes compared to those resulting from

group employment options.8 While research has shown that Supported Employment benefits

individuals regardless of their primary disability, there is evidence suggesting significant

disparities in who is offered the service. Compared to individuals with mild or moderate ID, a

significantly lower proportion of Supported Employment services are offered to individuals with

severe or profound intellectual disabilities.9 In addition, there seemed to be conflicting

5 Paul Wehman, Fong Chan, Nicole Ditchman, and Hyun-Ju Kang, Effect of Supported Employment on Vocational Rehabilitation Outcomes of Transition-Age Youth with Intellectual and Developmental Disabilities: A Case Control Study. Intellectual and Developmental Disabilities: Vol. 52, No. 4, pp. 296-310(2014). 6 Cimera, Robert E., The cost efficiency of supported employment programs: a literature review, Journal of Vocational Rehabilitation, 14 51–61, ISSN 1052-2263 IOS Press (2000). 7 Cimera, Robert E., The cost-trends of supported employment versus sheltered employment, Journal of Vocational Rehabilitation, Vol. 28, No. 1, pp. 15-20, (2008). 8 Kregel, John, Wehman, Paul and Banks, David P., The effects of consumer characteristics and type of employment model on individual outcomes in supported employment, Journal of Applied Behavior Analysis, 22 (4), , 407 – 415 (1989). 9 Moore, Corey L., Harley, Debra A., and Gamble, David, Ex-Post-Facto Analysis of Competitive Employment Outcomes for Individuals with Mental Retardation: National Perspective. Mental Retardation, Vol. 42, No. 4, pp. 253-262 (2004).



evidence as to the financial impact for people with severe or profound disabilities10 and there

was little evidence shown on the impact of having multiple disabilities on the benefit of

Supported Employment.11

Research by Qlarant (formerly Delmarva Foundation) has shown the importance of receiving

Supported Employment and its impact on individual outcomes. Using the Council on Quality

and Leadership’s (CQL) 25 Personal Outcomes Measures, it was found that Supported

Employment was the only service to significantly increase the total number of personal

outcomes present. Supported Employment significantly increased the likelihood individuals

were active participants in making decisions regarding where they worked and their daily

routines and were also more likely to live in integrated environments, participate in the

community, interact with community members and perform multiple social roles. Predicted

probabilities indicated Supported Employment in conjunction with Supported Living Coaching

(similar to Community Living Supports provided in Georgia) services was a particularly beneficial

combination of services. Individuals who received both of these services experienced increased

probabilities of choosing a daily routine, living in integrated environments and interacting with

the community.12 Further, more recent research has shown that receiving Supported

Employment is more beneficial than receiving any other service in supporting community

integration and rights for the individual.13

Data from the National Core Indicator Adult Consumer Survey© (NCI) (FY 2013 – FY 2017)

indicate Georgia may rank behind the NCI average in some employment areas. Data show

some variation in the employment rates for people with IDD who are working in integrated

settings (group or individual), between eight and 18 percent (see Figure 1).14 During the same

timeframe, the NCI national average ranged from 15 percent in FY 2013 to 19 percent in FY

2017. Georgia’s rates were significantly lower than the NCI average in FY 2014 and FY 2015.15

10 Lam, C.S., Comparison of sheltered and supported work programs: A pilot study, Rehabilitation Counseling Bulletin 30(2), 66–82 (1986). McCaughrin, W.B., Ellis, W.K., Rusch, F.R. and Heal, L.W., Cost-effectiveness of supported employment, Mental Retardation 31 (1993), 41–48. 11 Cimera, R.E., Are individuals with severe or multiple disabilities cost-efficient to serve via supported employment? Mental Retardation, 36, 280–292(1998). 12 Qlarant (formally Delmarva Foundation) for the Florida Statewide Quality Assurance Program, Outcome Results Analysis: Impact of Waiver Services on POM Outcomes Present, August 2007. 13 Qlarant (formally Delmarva Foundation) for the Georgia Division of Developmental Disabilities, Provider Systems and Driver Outcomes, June 2014. 14 Each year the state pulls a random sample of individuals to take part in NCI. Individuals are excluded if interviewed the previous year. Selection into the sample is random and answers are confidential. 15 Provided by HSRI from NCI Georgia and National data.



NCI data in Figure 2 show the percent of individuals each year who did not have a job in an

integrated setting, but wanted one. The rate remained approximately 50 percent between FY

2013 and FY 2017, and is similar to the NCI average.

If the person wants a job, there should be a goal of employment in the person’s service plan.

During the same timeframe (as in Figures 1 and 2), data in Figure 3 show 20 percent or fewer

individuals in Georgia without a paid job had an employment goal as part of the Service Plan.

The Georgia rates were significantly lower than the NCI average in each fiscal year, except FY

2013.

16% 8% 12%18% 16%

15% 16% 17% 19% 19%

0%

25%

50%

75%

100%

2012-13 2013-14 2014-15 2015-16 2016-17

Figure 1. Person Has a Job in an Integrated Setting

FY 2013 - FY 2017

GA NCI Average

48%55% 50% 49%

43%

49% 49% 49% 47% 46%

0%

25%

50%

75%

100%

2012-13 2013-14 2014-15 2015-16 2016-17

Figure 2. Person Does Not Have a Job and Wants a Job

FY 2013 - FY 2017

GA NCI Average



The purpose of this study is to help DBHDD further identify and document the financial and

personal benefits of receiving Supported Employment. Through a series of statistical models

and controls, we examine the association between the average cost of services per year with

(1) receiving Supported Employment, (2) the association of having this service on various

outcomes for an individual, including community integration, choice, and person centered

practices, and (3) if certain components of Support Coordinator performance improve the

likelihood of receiving Supported Employment. The research questions are as follows:

Is the total average cost of services for people receiving Supported Employment lower

than for people who do not receive this service?

Are personal outcomes for people receiving services better if receiving Supported

Employment?

Are there components of Support Coordinator performance, based on documentation

from the Support Coordination records, associated with whether or not an individual

receives Supported Employment?

The results of this study are intended to assist DBHDD and the Collaborative to target training

or quality improvement initiatives that could potentially lower the overall cost of services while

improving outcomes for individuals receiving those services.

Data

The analyses were conducted using three different sources of data, each including three fiscal

years from July 2015 through June 2018: Medicaid Claims data from GAMMIS (Georgia

19% 8% 16% 20% 16%

24% 25% 28% 30% 28%

0%

25%

50%

75%

100%

2012-13 2013-14 2014-15 2015-16 2016-17

Figure 3. Person Wants a Job and Has Employment as

Goal in the Service Plan

FY 2013 - FY 2017

GA NCI Average



Medicare and Medicaid Information System), demographic data from DBHDD Client

Information System (CIS) and quality data from the PCR process, completed onsite by Qlarant

reviewers.

Claims data include all individuals who have received a service through the NOW or COMP

waiver for which a claim has been filed and processed, and were used to determine the

association of Supported Employment with the average annual cost of services. Quality data

from the PCR were used to determine the association between Supported Employment and

personal outcomes of individuals receiving services. Quality data were also used to examine the

association between documented Support Coordinator performance and the likelihood of

having Supported Employment.

The PCR used a random probability sample of 480 eligible individuals, selected annually from

across the state and stratified by region. The list of eligible individuals (age 18 or over receiving

services through the NOW or COMP waiver) was taken from the state’s Consumer Information

System (CIS). This data source houses information for all individuals actively receiving HCBS

waiver services and also provides information from the Health Risk Screening Tool (HRST) used

to calculate a Health Care Level.16

Three years (July 2015 to June 2018) of data were used to enhance the power of the analyses.

The following exclusions apply, resulting in a total of 12,049 individuals for the cost analysis and

1,236 individuals for the quality analyses of outcomes and Support Coordinator performance:

One hundred and seventy-five people were excluded from the claims, as they had no

waiver type indicator.

One hundred and fifty-four people were excluded from the claims analysis, as they had

no Health Care Level (HCL) identified in CIS. 17

As access to claims for state funded services (SFS) is limited, individuals who utilized

only state funded services were excluded from the study. This is generally about 9-10

percent of the eligible population for each year of the study.18

The NCI Adult In-Person Survey is part of the PCR process, therefore, children age 17 or

younger are excluded from the PCR sample each year.

16 See the Independent (Control) Variable section of the study for more information on the Health Care Level. 17 HCL is calculated from the Health Risk Screening tool (HRST), discussed in the Independent Variable section. 18 The PCR data contain information on the funding source.



Thirty-one individuals had more than one PCR conducted during the three-year study

period. For these individuals, the most recent reviews were retained, removing any

duplicates from the analysis.

People who only receive the following services were excluded from the eligible

population each year, as they were not reviewed per the Collaborative’s contract with

DBHDD: Environmental Accessibility Adaptation, Financial Support Services, Georgia

Crises Response System (GCRS), Hospital Residential Services, Individual Directed Goods

and Services, Natural Support Training Services, Specialized Medical Equipment,

Specialized Medical Supplies, Transition Services, or Vehicle Adaptations.

Services received through the waivers, and identified in this study, are described by DBHDD as

follows:

Nursing Services are indicated when the individual has a clinical diagnosis which

requires ongoing complex assessment and intervention for the purpose of health

restoration or prevention of further deterioration of the health of the individual.

Nursing care is the assessment and treatment of human responses to actual or potential

health problems as identified through the nursing process. Thusly, nursing services are

the provision of this level of care via the process of assessment, assignment of nursing

diagnosis, planning, implementation/intervention and continued evaluations directed by

the Georgia Nurse Practice Act and generally accepted standards of practice.

Community Access Group (CAG) or Individual (CAI) is designed to help participants

acquire, retain or improve self-help, socialization and adaptive skills required for active

participation and independent functioning outside the home. It can be provided in a

group or individually.

Community Living Support (CLS) services are individually tailored supports that assist

with the acquisition, retention or improvement of skills related to participants’

continued residence in their family or own home.

Community Residential Alternative (CRA) are available to individuals who require

intense levels of residential support in small group settings of four or fewer or in host

home/life-sharing arrangement. Services include a range of interventions that focus on

training and support in one or more of the following areas: eating and drinking,

toileting, personal grooming and health care, dressing, communication, interpersonal

relationships, mobility, home management and use of leisure time.

Positive Behavioral Supports Consultation (PBSC) services are those that assist the

participant with significant, intensive challenging behaviors that interfere with activities



of daily living, social interaction, work or similar situations. These services consist of

comprehensive functional and diagnostic assessment of challenging behavior,

development of positive behavior support plans, training of identified professional and

supervisory staff responsible for training of direct support staff/informal care providers,

and routine review of program efficacy and adjustments to the plan based on review

findings.

Prevocational Services prepare participants for paid or unpaid employment and include

teaching concepts such as compliance, attendance, task completion, problem solving

and safety.

Respite Services provide brief periods of support or relief for individuals with disabilities

or their caregivers and include maintenance respite for planned or scheduled relief or

emergency/crisis respite for a brief period of support for participants experiencing crisis

(usually behavioral) or in instances of family emergency.

Support Coordination is a set of interrelated activities that identify, coordinate and

review the delivery of appropriate services with the objective of meeting the identified

needs and preferences of participants while protecting their health and safety and

ensuring access to services.

Supported Employment enables participants, for whom competitive employment at or

above the minimum wage is unlikely absent the provision of supports, to work in a

regular work setting.

Transportation, Financial Support, and Specialized Medical Services are additional

services provided to individuals during the study period, but are not reviewed during the

PCR.

Table 1 shows the number and percent of individuals who received these services over the

three-year study period. The shaded services were received by the individual but are either not

reviewed during the PCR (as per DBHDD agreed upon procedures) or not often received (small

sample sizes). These are combined into an “other services” category for analysis. People in the

sample were most likely to receive Community Access Group (87.5%) and approximately 13

percent of individuals in the sample received Supported Employment.



Table 1: Services Received by the Person19

Claims Data Population and PCR Sample

July 2015 - June 2018

Claims

(Population) PCR

(Sample)

Community Access Group 10,356 85.9% 1,081 87.5%

Community Access Individual 4,317 35.8% 390 31.6%

Community Living Supports 4,468 37.1% 372 30.1%

Community Residential Alternative 4,478 37.2% 556 45.0%

Prevocational 2,222 18.4% 241 19.5%

Supported Employment 1,436 11.9% 157 12.7%

Behavioral Supports 873 7.2% 81 6.6%

Nursing 573 4.8% 62 5.0%

Specialized Medical 3,288 27.3% 318 25.7%

Financial 2,084 17.3% 94 7.6%

Transportation 179 1.5% 12 1.0%

Respite 1,073 8.9% 68 5.5%

Number of Individuals 12,049 1,236

Demographic data (waiver type, race, gender, age, HCL, and level of IDD [mild, moderate,

severe, profound]) were taken from CIS and merged with the claims data and PCR sample.

Figures 2 – 5 provide a demographic description of individuals included in the Claims and PCR

data sources. One exception was information on the individual’s residential setting which was

available consistently in the PCR data. Within each demographic, the percent of individuals in

the PCR sample is similar to the percent in the eligible population (Claims Data). Results in

Figures 2 – 5 show individuals were:

More likely to receive services through the COMP waiver as opposed to the NOW waiver

(Figure 4)

More likely to be male than female (Figure 4)

More likely to live with a parent as opposed to in a group home or host home, or in their

own place (available for the PCR sample only) (Figure 4)

Most likely to be age 22 to 44 (The PCR sample excludes children under age 18) (Figure

5)

19 People likely receive more than one service. For example, an individual receiving Community Access Group will also receive Support Coordination.



Most likely to have a Low Risk HCL score (1 or 2), as opposed to Medium Risk (3 or 4) or

High Risk (5 or 6)20 (Figure 6)

Most likely to have a Mild or Moderate level of ID as opposed to Severe or Profound

(Figure 7)

20 Calculated from the HRST as described in the Independent Variable section.

41.7%

13.1%

45.1%

41.5%

58.5%

4.0%

48.9%

47.1%

66.9%

33.1%

40.9%

59.1%

4.1%

51.1%

44.8%

65.0%

35.0%

0% 25% 50% 75% 100%

Group/Host Home

Own Place

With Parents

Female

Male

Other

White

Black

COMP

NOW

Figure 4: Distribution Across Demographics

Claims Data vs. PCR Sample

Claims Data (N = 12,049) PCR Sample (n = 1,236)



Figure 5. Distribution across Age Groups


Age Group

< 18

18 - 21

22 - 44

45 - 54

55 - 64

65+

Claims Data(N = 12,049)

1.3%

2.5%

54.7%

18.4%

15.0%

8.0%

PCR Sample(n = 1,236)

NA

0.2%

56.2%

17.4%

18.2%

8.0%

66.6%

22.2%11.2%

66.5%

22.0%11.5%

0%

25%

50%

75%

100%

Low Risk Moderate Risk High Risk

Figure 6. Health Care Level


Claims Data (N = 12,049) PCR Sample (n = 1,236)



Methods

This study is separated into three distinct analyses listed below. In each analysis, a multivariate

regression was used to determine the net impact of the independent (control or explanatory)

variables on the dependent variable, controlling for other factors that may influence the

identified outcome (described below). Multivariate analysis results include regression

coefficients or odds ratios and p-values.

The first analysis utilizes Ordinary Least Squares (OLS) to explore the hypothesis if the

average cost of services for individuals receiving Supported Employment is lower than

for individuals not receiving Supported Employment.

The second analysis employs logistic regression to explore the hypothesis if personal

outcomes for people receiving services through the DHBDD system are better if

receiving Supported Employment.

The third analysis employs logistic regression to explore the hypothesis if different

components of a Support Coordinator’s documentation (performance) are associated

with whether or not the individual receives Supported Employment.

When a dependent variable is measured on a continuous scale (e.g., cost of claims from $1.00

to $10,000), OLS regression techniques are used. A regression coefficient indicates the

strength and direction of the relationship between the independent (also referred to as

explanatory as they are used to “explain” the outcome) and dependent variable. A positive

coefficient indicates increasing values of the independent variable result in increasing values of

the dependent variable. A negative coefficient indicates increasing values of the independent

73.8%

26.2%

77.0%

23.0%

0%

25%

50%

75%

100%

Mild/ Moderate Severe/ Profound

Figure 7. Level of IDD


Claims (N=11,359) PCR Sample (n=760)



variable result in decreasing values of the dependent variable. In fact, the coefficient tells us the

size of the change in the dependent variable for a unit change in the independent variable. For

example, in Table 4, the coefficient for Age (COMP; 0.13) indicates that for every year of

increase in age, the average cost of services increases by $130.

When the dependent variable is categorical, such as scoring above or below a 90 percent on

outcomes, logistic regression techniques are used. Odds Ratios (OR) show the strength of a

relationship and represent the percent change in the odds of being present on the dependent

variable for a unit change in the independent variable. An OR greater than one (>1.0) indicates

a positive relationship, or that an increase on the independent variable is associated with an

increase on the dependent variable. Odds ratios between 0 and 1 indicate a negative or inverse

relationship, where an increase on the independent variable is associated with a decrease in

the outcome. An odds ratio of 1 means the odds are the same, regardless of the response on

the independent variable.

The farther away the odds ratio is from one, the stronger the relationship. For example, in

Table 6, the Odds of having safety outcomes met (OR = 2.57) was over two and a half times

greater for individuals who receive Supported Employment vs. those who do not. Individuals

with severe/profound ID were approximately half as likely (OR = 0.60) to have Community Life

outcomes met, compared to individuals with mild to moderate ID. Waiver type (NOW vs

COMP) showed an OR of 1.00 for Person Centered Practices (PCP) meaning there was no

difference in PCP outcomes based on the funding source.

The p-value or probability value is the probability the relationship between two variables is due

to sampling error and is used to determine the statistical significance of the relationship

between the independent variable and the dependent variable. A p-value of .05 or smaller

indicates the chance of this being an error is five percent or less. A p-value of .10 indicates a 10

percent chance or less the results are due to sampling error. Statistical significance levels are

arbitrary and depend upon how much error is acceptable in the model or research area. For this

research, DBHDD has determined a p-value of 0.01 will determine statistical significance. P-

values are provided for all analyses.

Independent (Control) Variables

Demographics

Several demographic control variables were used in this analysis: age, gender, race, waiver

type, severity of ID diagnosis, residential setting, and services received at the time of the PCR.



While age is a continuous variable measured in years, all other control variables are either

dichotomous or categorical with an assigned reference group (the reference group in

parentheses). When interpreting results, they are in comparison to the reference group:

Male (Female)

White (Non-White)

COMP (NOW)

IDD Level – Severe/Profound (Mild/Moderate)

Residential Setting – Own Place (Group Home/Host Home)

Residential Setting – With a Parent (Group Home/Host Home)

Each service is compared to all other services

Health Care Level (HCL)

The Health Risk Screening Tool (HRST) determines individuals’ Health Care Level (HCL). The

HRST was developed by Health Risk Screening, Inc. and is utilized by nine states, including

Georgia and over 2,000 private provider agencies in the United States. It is used to screen for

health risks associated with a wide variety of disabilities, including developmental disabilities,

and is designed to detect health destabilization early, as well as to help prevent illness, health

related events and even death. The HRST consists of 22 rating items, divided into five health

categories and with a numeric degree of health risk called a Health Care Level (HCL), ranging

from 1 (low risk) to 6 (high risk) (http://hrstonline.com). In this analysis, the HCL is separated

into three categories for which a score of 1-2 is considered “Low Risk”, a score of 3-4 is

“Medium Risk,” and a score of 5-6 is “High Risk.” The reference group in each analysis is “Low

Risk.”

HCL High Risk (Low Risk)

HCL Medium Risk (Low Risk)

Table 2 provides a distribution of demographic variables used in the Personal Outcome and

Support Coordinator analysis (PCR sample data), showing the number and percent of

individuals in each category receiving Supported Employment. For individuals receiving

Supported Employment, the differences between male and female and between white and

non-white were relatively small, 2.2 and 3.1 percentage points respectively. Other findings

indicate individuals were more likely to receive Supported Employment:

When receiving services through the NOW vs the COMP waiver (9.8% vs. 7.6%)



If they had a mild or moderate vs severe or profound ID diagnosis (11.3% vs. 2.2%)

If they had low health risk level (11.8%)

If they lived in their own home (22.2%)

When receiving Community Access Individual (13.3%) or Community Living Supports

(11.0%) services

Table 2: Demographic Categories: Percent Receiving Supported Employment (SE)

Person Centered Reviews: July 2015 - June 2018 (N = 1,236)

Demographic Variable Total Percent # With SE % With SE

Gender

Female 513 41.5% 39 7.6%

Male 723 58.5% 71 9.8%

Race

White 604 48.9% 44 7.3%

Non-White 632 51.1% 66 10.4%

Waiver Type

COMP 827 66.9% 52 6.3%

NOW 409 33.1% 58 14.2%

Individual has Severe/Profound ID

No 912 73.8% 103 11.3%

Yes 324 26.2% 7 2.2%

Home Type

Group/Host Home 516 41.7% 19 3.7%

Own Place 162 13.1% 36 22.2%

With Parents 558 45.1% 55 9.9%

Service Types

Community Access Group

1,081 87.5% 84 7.8%

Community Access Individual

390 31.6% 52 13.3%

Community Living Supports

372 30.1% 41 11.0%

Community Residential Alternative

556 45.0% 22 4.0%

Prevocational 241 19.5% 9 3.7%

Other Services 474 38.3% 25 5.3%

Health Care Level

Low Risk (Level 1-2) 822 66.5% 97 11.8%



Table 2: Demographic Categories: Percent Receiving Supported Employment (SE)

Person Centered Reviews: July 2015 - June 2018 (N = 1,236)

Demographic Variable Total Percent # With SE % With SE

Moderate Risk (Level 3-4)

272 22.0% 8 2.9%

High Risk (Level 5-6) 142 11.5% 5 3.5%

Age N Mean N Mean 1,236 44.5 110 42.4

Support Coordinator Documentation (Support Coordinator Record Review)

The third analysis described in the Methods section examines if different components of a

Support Coordinator’s documentation (performance) are associated with whether or not the

individual receives Supported Employment. Support Coordinator performance is measured

using indicators from the SCRR. One SCRR is completed for each individual who participates in

the PCR. Therefore, a total of 1,236 SCRRs (FY 2015 to FY 2018) were used in the analysis.

Results from these record reviews were used to examine the relationship between the Support

Coordinator’s documentation of services and the likelihood individuals receive Supported

Employment.

The SCRR indicators are organized around the FOAs, as described for the Individual Interview.

Also like the Individual Interview, scores for the SCRR were limited in their variability – not

lending themselves well to OLS Regression. Using logical cutoff values in the distribution of the

data, dichotomous variables were created for each SCRR independent variable used in the

analysis. The SCRR is analyzed with scores greater than or equal to 75 percent versus less than

75 percent. In the final analyses, Whole Health and Safety were excluded as they did not have

enough variation. The average overall score for the SCRR was 78.5 percent, ranging from 60.5

percent for Rights to 95.9 percent for Safety (Figure 8).



Expectations

Several FOAs were examined through Exploratory Factor Analysis (EFA) to help determine the

validity and reliability of indicators used in the SCRR within each FOA. The EFA was completed

for Choice, Community Life and Person Centered Practices. Other FOAs did not have enough

variation for the analysis to run properly and produce valid results. Factors identified through

this analysis were categorized into Expectations and are used in the regression analysis models

to more deeply explore Support Coordinator performance, in addition to the Overall Score and

FOAs for the tool.21 See Appendix 1 for a list of variables identified for each Expectation.

Dependent Variables

Average Annual Cost of Claims

In the first analysis, Medicaid Claims from GAMMIS (Georgia Medicare and Medicaid

Information System) with a last date of service for July 1, 2015 – June 30, 2018 were used to

calculate the average cost of claims per individual. The annualized average cost of claims per

individual for the three-year period ranged from $152.88 to $352,176.63. Over 95 percent of

individual costs were less than $100,000. To reduce the influence of high outliers, the variable

was capped at $100,000. After adjusting for outliers, the state three-year annualized average

21 The Support Coordinator standards were analyzed and reports provided to DBHDD. See Exploratory Factor Analysis Findings SCRR 04052018 for a detailed description of the methods and results.

71.9% 68.3%

82.0%

60.5%

95.9% 95.7%

78.5%

0%

25%

50%

75%

100%

Choice CommunityLife

PersonCenteredPractices

Rights Safety WholeHealth

OverallScore

Figure 8. Average SCRR Score by FOA

July 2015 - June 2018



cost of claims reduced from $42,791.72 to $39,828.72, with 12,049 claims available for the

analysis. 22

Personal Outcomes

In the second analysis, the association between receiving Supported Employment and personal

outcomes was analyzed using the Individual Interview conducted during Qlarant’s Person

Centered Reviews (PCR) between July 1, 2015, and June 30, 2018. The Individual Interview is

organized around six FOAs measuring various outcomes pertinent to an individual’s quality of

life: Choice, Community Life, Person Centered Practices, Rights, Safety, and Whole Health. The

Overall score from the interview and scores for each of the FOAs were analyzed using the

percent met, calculated as the total number of standards met divided by the total number met

or not met.

Scores for the Individual Interview tended to be high and are limited in their variability – not

lending themselves well to OLS Regression. Instead, based on the average scores and

distribution of the variables, a value of 90 percent or higher was used to dichotomize each of

the FOA measures, making them suitable for logistic regression. In the final analyses, Rights was

excluded, as there was not enough variation in the distribution of results from the interviews.

The average overall score for the Individual Interview was 93.0 percent, ranging from 82.3

percent for Community Life to 97.9 percent for Rights (Figure 9).

22 Three percent (n = 365) of individuals in the state had an average cost of over $100,000 during the 3 year study period.



Receiving Supported Employment Services

For the third analysis, an indicator identifying if the individual receiving services had Supported

Employment at the time of the PCR (1) or not (0) is used as the dependent variable. This model

is used to explore how different aspects of Support Coordinator performance, based on the

Support Coordinator Record Review (SCRR) documentation, are associated with whether or not

the individual receives Supported Employment. SCRR documentation is reviewed and scored to

determine how well the coordinator advocates for the individual, and provides choices to help

ensure services are provided as needed.

Results

Supported Employment and Cost of Claims

Average Cost by Service

The first purpose of this study is to examine the association of the average annual cost of Home

and Community Based Services (HCBS) for people receiving Supported Employment versus

those not receiving this service. Information in Table 3 shows the average annual cost of

services, per individual, provided through the NOW or COMP waivers for the study period (July

2015 through June 2018). Community Residential Alternative (CRA) showed the highest

average cost per individual for services offered through the COMP waiver for the 4,478 people

who received CRA during the study period ($61,684.99). The cost for Supported Employment

was considerably lower per individual for 1,436 people who received the service ($2,896.96).

96.7%

82.3%89.3%

97.9% 93.9% 90.3% 93.0%

0%

25%

50%

75%

100%

Choice CommunityLife

PersonCenteredPractices

Rights Safety WholeHealth

OverallScore

Figure 9. Average Individual Interview Score by FOA

July 2015 - June 2018



Table 3. Average Cost of Claims by Service and Waiver Type23

July 2015 - June 2018

Service NOW

(n = 4,221)

COMP

(n = 7,828)

Statewide

Average Cost

(N = 12,049)

Community Access Group (p<.0001) $9,301.61 $11,722.27 $10,905.56

Community Access Individual (p<.0001) $3,340.10 $4,416.90 $4,022.80

Community Living Supports (p<.0001) $7,425.28 $21,365.86 $19,035.15

Community Residential Alternative (p<.0001 )24

. $61,648.99 $61,648.99

Prevocational (p = .22) $5,704.39 $5,458.47 $5,582.76

Supported Employment (p = .009) $2,726.36 $3,063.33 $2,896.96

Behavioral Supports (p = .002) $1,207.07 $1,778.86 $1,741.53

Nursing (p = .68) $20,272.50 $33,683.77 $33,636.96

Specialized Medical (p<.0001) $1,266.08 $1,837.60 $1,762.86

Financial (p<.0001) $692.99 $767.00 $749.28

Transportation (p = .0002) $825.31 $1,278.82 $1,017.86

Respite (p<.0001) $1,665.94 $2,207.28 $2,082.67

Average Total Cost (p<.0001) $13,694.98 $53,920.50 $39,828.72

Net Impact on Cost of Services (Regression Analysis)

Many circumstances factor into the cost of services provided to people with IDD, including the

complexity of diagnosis, number and type of services needed, and the general health of the

individual. Not all are available for this analysis; however, all relevant factors from the review

processes were used to more accurately predict the net impact of receiving Supported

Employment on the average cost of services per individual (See Table 4). Because the cost of

services is of particular interest to DBHDD and the cost varies by funding source, the analysis

was completed separately (two separate regression models) for individuals receiving services

through the NOW or COMP waiver.

Findings from the two models are presented in Table 4. Information includes the regression

coefficient, representing thousands of dollars, and the p-value for each coefficient. The

coefficient shows the net impact of the independent variable on the average cost of services.

The technique controls for all factors listed in Table 4, i.e., the net impact for someone who is

the same age, race, and gender, with the same ID severity level and HCL, who is receiving the

23 For individuals on the NOW waiver, only 76 (1.8%) individuals had a High HCL and only three individuals received Nursing services. 24 CRA is not offered through the NOW waiver.



same services. For example, controlling for these factors (ceteris paribus), the cost of services

received through the COMP waiver for individuals with profound or severe ID levels is $3,460

greater on average than the cost for people with mild to moderate ID levels (Coefficient=3.46;

p-value < .0001). On the other hand, for individuals with profound or severe ID receiving

services through the NOW waiver the cost is nearly $1,000 greater on average

(Coefficient=0.96; p-value < .0001).

Results with a negative coefficient (lower cost) and a p-value less than 0.05 are shaded in light

blue. Those with a positive coefficient (higher cost) and a p-value under 0.05, are shaded in

peach. Findings indicate:

The average cost of services for someone receiving Supported Employment through the

COMP waiver was $2,110 less than for someone not receiving this service. The average

cost for an individual receiving Supported Employment through the NOW waiver was

$2,720 less than someone not receiving this service.

On the other hand, the average cost of receiving Community Residential Alternative in a

licensed group home was $39,920 (COMP) more when compared to receiving any other

service.

For individuals on the COMP waiver, a Medium or High HCL is associated with a $3,520

or $14,650 increase in the average cost of services, respectively.

An increase in age is correlated with slightly higher costs for individuals on the COMP

waiver - $130 more, on average, for every year of age.

Table 4: OLS Regression of Average Cost of Claims25

Regression Coefficients In Thousands of Dollars (NOW and COMP)

July 2015 – June 2018 (N = 12,049)

NOW COMP

(n = 4,221) (n = 7,828)

Supported Employment -2.72 -2.11

(p<.0001) (p<.0001)

Age 0.00 0.13

(p = .72) (p<.0001)

Gender ( 1= Male; 0 = Female) 0.39 0.97

25 The Constant (where the regression line passes through the y-axis) from the models are not shown. The coefficient was 9.64 in the NOW model and 16.59 in the COMP model, both with a p value <.0001.



Table 4: OLS Regression of Average Cost of Claims25

Regression Coefficients In Thousands of Dollars (NOW and COMP)

July 2015 – June 2018 (N = 12,049)

NOW COMP

(n = 4,221) (n = 7,828)

(p = .009) (p = .009)

Race (1 = White; 0 = All other races) -0.66 -0.82

(p<.0001) (p = .02)

Severity ( 1 = Profound/Severe; 0 = Mild/Moderate)

0.94 3.46

(p<.0001) (p<.0001)

HCL Medium Risk vs. Low Risk -0.38 3.52

(p = .14) (p<.0001)

HCL High Risk vs. Low Risk -0.89 14.65

(p = .13) (p<.0001)

Community Access Group 4.11 4.19

(p<.0001) (p<.0001)

Community Access Individual 0.53 -1.18

(p = .0006) (p = .003)

Community Living Supports 2.00 -1.18

(p<.0001) (p = .04)

Community Residential Alternative - 39.92

(p<.0001)

Prevocational 1.43 -0.65

(p<.0001) (p = .23)

Other Services 0.21 3.53

(p = .30) (p<.0001)

Personal Outcomes and Supported Employment

The second purpose of this study is to explore the association of having Supported Employment

services with an individual’s outcomes. Are outcomes such as choice or community involvement

better if the individual has Supported Employment? The analysis was completed with data from

the face-to-face PCR Individual Interview (II). The interview standards/indicators are grouped

into six different Focused Outcome Areas (FOA): Choice, Community, Person Centered

Practices, Rights, Safety and Health.26 Outcomes were analyzed as an overall interview score

and by each FOA. 26 The FOAs are described in detail in the GA DBHDD ASO Annual Quality Reports.



Outcome Score by Focused Outcome Areas

As described in the Methods section, the individual outcomes analysis examines the association

of individuals who had 90 percent or more outcomes met compared to individuals with less

than 90 percent met. The following table shows the proportion of individuals with 90 percent

or more of outcomes present for the Overall II score and by FOA, for individuals who had

Supported Employment and those who did not. Findings (Table 5) indicate individuals with

Supported Employment were significantly more likely to have 90 percent or more outcomes

present overall (Overall II Score, p<.0001). Findings also indicate individuals with Supported

Employment were significantly more likely to have 90 percent or more of indicators present

measuring Choice, Community Life, Person Centered Practices, Safety and Whole Health.

Table 5. Personal Outcomes (Individual Interview)

Percent with Score of 90% or More

FOA

Supported

Employment

Non-Supported

Employment

(n = 110) (n = 1,126)

Choice (p = .0009) 98.8% 96.5%

Community Life (p <.0001) 90.0% 81.6%

Person Centered Practices (p = .002) 93.0% 88.9%

Rights (p = .03) 98.7% 97.9%

Safety (p = .0002) 97.4% 93.5%

Whole Health (p = .0004) 93.9% 89.9%

Overall II Score (p<.0001) 96.0% 92.7%

Net Impact of Supported Employment on Personal Outcomes (Logistic Regression)

Results for the logistic regression are shown in Table 6. Six different models were tested, each

using the same independent variables but independently testing their association with the

Overall Score for outcomes and the score for each FOA. Because there was minimal variation

for Rights scores, this FOA was excluded from the analysis. Odds Ratio (OR) for each

independent variable in the model are shown in Table 6. Findings with an OR between 0 and 1

and a p-value less than 0.05 are shaded in light blue (lower odds of having ≥90% of outcomes

present). Those with an OR over 1 and a p-value under 0.05 (higher odds of having ≥90% of

outcomes present), are shaded in peach. Key findings of interest indicate:



Individuals with Supported Employment were two times more likely (OR = 2.03) to have

90 percent or more of outcomes present, compared to individuals without Supported

Employment. A value of 0.02 indicates a two percent chance this result is due to

sampling error.

Among the FOAs, having Supported Employment was positively associated with

Community Life (OR = 1.65), Safety (OR = 2.57), and with a slightly higher p-value of

0.05, Person Centered Practices (OR = 1.65).

Other shaded areas show categories of the independent variables that may be

associated with higher or lower levels of personal outcomes.

Waiver Type, NOW vs. COMP did not show any association with the Overall Score or any

FOA.

Table 6. Logistic Regression of Individual Interview Outcomes - Score ≥ 90.0%

July 2015 - June 2018 (N = 1,236)

Dependent Variable: Personal Outcomes Independent

Variables

Overall

Score Choice

Community

Life PCP Safety

Whole

Health

Supported

Employment

2.03 (p = .02)

1.93 (p = .22)

1.65 (p = .02)

1.65 (p = .05)

2.57 (p = .01)

1.15 (p = .56)

Age 1.00

(p = .89) 1.01

(p = .29) 1.00

(p = .85) 1.00

(p = .94) 1.00

(p = .49) 0.99

(p = .03)

Gender ( 1= Male) 0.85

(p = .25) 0.64

(p = .03) 0.83

(p = .12) 0.85

(p = .18) 0.80

(p = .13) 0.96

(p = .72)

Race (1 = White) 1.13

(p = .39) 0.90

(p = .58) 1.17

(p = .20) 0.92

(p = .48) 1.09

(p = .55) 1.08

(p = .54)

Waiver Type (1 = COMP)

0.76 (p = .32)

0.66 (p = .36)

1.10 (p = .68)

1.00 (p = .99)

0.83 (p = .52)

0.96 (p = .87)

Severity (1 = Profound/ Severe)

0.48 (p<.0001)

0.74 (p = .17)

0.64 (p = .002)

0.75 (p = .05)

0.48 (p <.0001)

0.55 (p<.0001)

HRST Medium vs. Low Risk

0.85 (p = .27)

1.43 (p = .11)

0.74 (p = .23)

0.72 (p = .04)

0.80 (p = .15)

0.87 (p = .27)

HRST High vs. Low Risk

1.05 (p = .55)

0.93 (p = .40)

0.80 (p = .73)

0.99 (p = .46)

1.07 (p = .44)

1.07 (p = .51)

Own Place vs. Group/Host Home

1.66 (p = .18)

2.64 (p = .17)

2.14 (p = .03)

1.75 (p = .04)

3.81 (p = .02)

1.87 (p = .02)



Table 6. Logistic Regression of Individual Interview Outcomes - Score ≥ 90.0%

July 2015 - June 2018 (N = 1,236)

Dependent Variable: Personal Outcomes Independent

Variables

Overall

Score Choice

Community

Life PCP Safety

Whole

Health

With Parents vs. Group/Host Home

1.10 (p = .58)

1.24 (p = .57)

1.48 (p = .97)

0.94 (p = .17)

2.06 (p = .99)

0.96 (p = .15)

Community Access Group

0.96 (p = .87)

0.47 (p = .06)

0.94 (p = .75)

1.44 (p = .06)

0.87 (p = .57)

0.62 (p = .02)

Community Access Individual

1.40 (p = .03)

1.49 (p = .10)

1.28 (p = .06)

1.47 (p = .006)

1.14 (p = .44)

1.23 (p = .14)

Community Living Supports

1.22 (p = .42)

1.52 (p = .28)

0.83 (p = .36)

0.90 (p = .63)

1.40 (p = .21)

1.109 (p = .70)

Community Residential Alternative

1.43 (p = .43)

0.78 (p = .71)

1.26 (p = .51)

1.08 (p = .85)

3.05 (p = .08)

0.88 (p = .71)

Prevocational 1.20

(p = .61) 1.52

(p = .17) 0.85

(p = .30) 1.05

(p = .78) 1.70

(p = .02) 0.97

(p = .87)

Other Services 0.67

(p = .02) 0.77

(p = .27) 0.96

(p = .80) 0.90

(p = .50) 0.70

(p = .04) 0.80

( p = .14)

Support Coordinator Performance

The final purpose of this study is to explore if any specific area of Support Coordinator

performance is likely to impact the individual’s odds of having Supported Employment as a

service. The Overall Score and scores by FOA from the Support Coordinator Record Review

(SCRR) were used as predictor variables. FOAs were further examined by Expectation, as

appropriate, using the same independent controls.

SCRR Scores by Focused Outcome Area and Expectation

The following information (Table 7) shows the percent of SCRRs with scores of 75 percent met

or greater for individuals with and without Supported Employment.27 Results indicate the

following:

Compared with records for people who did not receive Supported Employment, Overall

Scores on the Support Coordinator Record Reviews were only slightly higher, on 27 As explained earlier, dichotomous variables were created for each SCRR independent variable used in the analysis, as explained for the Personal Outcomes from the interviews. Using logical cutoff values in the distribution of the data, the SCRR is analyzed with scores greater or equal to 75 percent versus less than 75 percent.



average, for individuals who did receive Supported Employment (78.3% vs. 80.9%,

p=0.12).

The differences between receiving Supported Employment or not appear to be greatest

for indicators within the Community Life FOA – especially in the Integrated Employment

expectation (78.2% vs. 41.3% scoring ≥ 75% present).

The Expectation Person’s Preferences, scored within the Person Centered Practices FOA,

also showed a difference between the individual’s likelihood of receiving Supported

Employment (91.8% vs. 81.3% scoring ≥75% met)

SCRR documentation scores were higher for individuals not receiving Supported

Employment on the Rights, Whole Health and Safety FOAs.

Table 7. Percent of SCRR Scores ≥ 75% Met by FOA and Expectation

Person Centered Reviews: July 2015 – June 2018 (N = 1,236)

FOA/Expectation

Supported

Employment

(n = 110)

No Supported

Employment

(n = 1,126)

Choice (p = .23) 75.0% 71.6%

Services and Home Life (p = .81) 64.6% 63.4%

Community and Employment (p = .08) 57.3% 48.5%

Community Life (p <.0001) 82.9% 66.9%

Community Integration (p = .01) 60.0% 47.6%

Integrated Employment (p<.0001) 78.2% 41.3%

Person Centered Practices (p = .23) 83.9% 81.8%

Person's Preferences (p = .006) 91.8% 81.3%

Monitoring Supports and Services (p = .83) 94.6% 95.0%

Evaluation and Modification of Supports and Services (p = .18) 58.2% 51.5%

Implementation and Needed Changes to Supports and Services (p = .18) 85.5% 80.2%

Response to Supports and Services (p = .34) 60.0% 55.2%

Rights (p = .01) 53.9% 61.2%

Safety (p<.0001) 92.6% 96.2%

Whole Health (p<.0001) 90.8% 96.2%

Overall SCRR Score (p = .12) 80.9% 78.3%

Net Impact of Support Coordinator Record Review Components

Logistic Regression models were used to examine the potential impact of different components

of Support Coordinator performance (SCRR) on the likelihood of having Supported

Employment. The Overall SCRR score and scores by FOA (Choice, Community Life, Person



Centered Practices, Rights) were entered separately, one per model. Because there is little

variation in the Safety and Whole Health FOAs, they were not analyzed. Independent variables

shown in the Individual Interview model were used in each SCRR model, but are not presented

in the tables.28 Odds ratios (OR) are presented in Table 8 for FOAs and in Table 9 for

Expectations.29 Findings indicate the following:

Support Coordinators with higher scores showing how the individual is supported on

the Community Life FOA were nearly two and a half times more likely to be supporting

people who had Supported Employment services (OR = 2.46).

The strongest Expectation in Community Life (Table 9) that impacted the likelihood of

receiving Supported Employment was if Support Coordinators showed how they support

individuals to acquire Integrated Employment (OR = 4.42). Three indicators are used to

measure this Expectation. Individuals were more likely to have Supported Employment

services when the Support Coordinator

o Demonstrated opportunities to seek employment and education in integrated

settings

o Reviewed and discussed opportunities with the individual

o Advocated to ensure the individual has the opportunity to actively participate in

activities and work the same as citizens without disabilities.

While the FOA for Person Centered Practices showed a very high p-value (0.93), the

Expectation of Person’s Preferences showed a p-value of .03 and OR of 2.28, a fairly

strong association with the person having Supported Employment. This Expectation

measures if the Support Coordinator documents:

o The individual’s strengths and communication style

o How the individual is working on goals that matter most

o How the Support Coordinator effectively solicits feedback regularly from the

individual.

Table 8. Logistic Regression of Supported Employment by SCRR Scores (FOA)

Odds Ratios July 2015 - June 2018

Dependent Variable: Supported Employment

Independent Variables Overall Score Choice

Community Life PCP Rights

SCRR FOA ORs (1 = ≥75%) 1.11 1.06 2.46 1.02 0.63

28 See Appendix 2 for full models. 29 Odds Ratios and p-values are presented in Appendix 2.



Table 8. Logistic Regression of Supported Employment by SCRR Scores (FOA)

Odds Ratios July 2015 - June 2018




(p = .66) (p = .81) (p = .0002) (p = .93) (p = .05)

Table 9. Logistic Regression of Supported Employment by SCRR

Expectation

July 2015 - June 2018


Community Life

Person Centered Practices

Independent Variables Integrated

Employment Person’s

Preferences

Expectation ORs (SCRR 1 ≥75%) 4.42

(p<.0001) 2.28

(p = .03)

Discussion and Recommendations

DBHDD has applied continuous quality improvement to the system that oversees the services

and supports provided to individuals with IDD. This Quality Improvement Study is a part of that

process, examining the impact of having Supported Employment on the average cost of services

and personal outcomes. The following summary of findings and recommendations are

provided to guide quality improvement initiatives and training to enhance services and

outcomes for people across the state.

Research Questions Summary

It has been shown throughout this study that receiving Supported Employment is associated

with a lower average cost of HCBS waiver services and improved outcomes related to

Community Life, Person Centered Practices and Safety for individuals receiving services.

Furthermore, specific components related to Community Life and Person Centered Practices

within Support Coordinator performance have been shown to be associated with an increased

likelihood individuals will receive Supported Employment services. Individuals are more likely to

have Supported Employment if Support Coordinators maintain quality documentation

demonstrating how people receiving services are supported to have a life in the community as

well as person centered approaches to service delivery. Further, compared to individuals who



do not receive Supported Employment, those who receive Supported Employment are more

likely to have certain personal outcomes met and lower average cost of services annually

(about $2,000) – regardless of waiver type.

Knowing the individual receiving services well and understanding each person’s strengths,

goals, interests and communication style are key in helping ensure people receive this service.

Knowing and understanding how to offer people informed choice and introducing them to

different places and opportunities to work in the community will help people receiving services

move toward work in integrated environments. The evidence presented in this study suggests

that Supported Employment services benefit the state of Georgia economically, while also

improving outcomes for individuals. Individuals who receive this service are typically more

integrated in their community allowing them to build stronger relationships with friends and

natural supports, which in turn strengthen safety and health outcomes.

Findings for Research Questions

Cost Analysis

Results in this study support previous research findings that supporting people to work in

integrated environments reduces the overall average cost of services. Data from the

Collaborative indicated the average annual cost of HCBS services, per individual, is about $2,000

less per year for people who receive Supported Employment. While it was not possible to

include all factors impacting the cost of services in the analysis (i.e., the degree of support an

individual may get from family or other natural supports), the cost finding was significant when

controlling for demographic characteristics, including age, race, gender, the level of Intellectual

Disability, Health Care Level, and the different services the individual received. A continued

focus on assisting individuals who receive services to gain competitive work through Supported

Employment will provide an economic advantage to the State.

Personal Outcomes

In addition to the cost benefit to the State, findings also support an increased likelihood the

individual who receives Supported Employment will have more personal outcomes present.

Based on the face-to-face interview completed during the Person Centered Reviews, individuals

with Supported Employment were twice as likely to score 90 percent or higher on outcomes,

compared to individuals not receiving the service. This association was substantial for the

Overall Score and for two FOAs: Community Life and Safety. The chance the associations were

due to sampling error was 0.02 or less.



When individuals have the support to work in integrated settings, the likelihood they will have a

more community-centered life increases. During the interview, individuals with Supported

Employment were more likely to report they:

Have community involvement and new experiences in the community

Have supports they need to be involved in the community

Identify valued social roles they have and learn about new roles

Are a member of a community group or club

Have goals related to employment that are actively pursued

The most robust relationship between personal outcomes and Supported Employment was for

the Safety FOA, for which individuals receiving Supported Employment were over two and a

half times more likely to have 90 percent or more outcomes present. During the interview,

individuals were more likely to indicate they:

Feel safe at home, in the community and at work

Are aware of emergency procedures in these different environments (home, work, and

the community)

Know how to respond to an emergency

Have reviewed and understand safety plans

Understand what constitutes abuse, neglect and exploitation and are free of these

Know who to go to if there is a safety concern

It is possible there is some amount of self-selection in that people (and families) who seek out

competitive employment are more likely to be self-confident or have people around them who

believe in their skills and abilities. This type of attitude and philosophy tends to permeate into

other parts of an individual’s life. Therefore, learning safety skills and being able to recognize

safety issues may become part of the individual’s abilities. When such a strong association is

identified it is also possible that exposure to work in a competitive environment, working with

people who do not have disabilities, and the resulting integration into the community may help

to improve the individual’s awareness of when abuse may be occurring or the importance of

knowing what to do in an emergency.

Support Coordinator Documentation

The final question, do some components of Support Coordinator performance impact an

individual’s likelihood of having Supported Employment, was researched to help offer guidance



in how to focus efforts to improve the rate at which Supported Employment is provided.

Documentation reflects supports and services provided to an individual. Therefore, the

assumption is if a Support Coordinator documents how various choices are offered to an

individual to make informed decisions, the activity is actually occurring. As a result, an

individual would be more likely to be exposed to and provided education on employment

options and these types of outcomes discussed in this work.

Support Coordinators who have documentation to show how they advocate for the individual

to participate in the community, build social roles and use community resources are over two

times more likely to work with people receiving Supported Employment. This relationship is

particularly strong (OR = 4.42) when documentation clearly shows how the individual is

supported to seek competitive employment and participate in integrated community settings.

These efforts, evidenced with quality documentation, specifically include demonstrating

opportunities to seek employment and education in integrated settings, discussing

opportunities with the individual, and advocating to ensure the individual has the opportunity

to actively participate in social activities and work the same as citizens without disabilities.

Supporting the individual’s personal strengths and preferences is also a good indicator of the

likelihood of receiving Supported Employment, as well as clear documentation of seeking

feedback from the individual. Clear feedback from the person receiving services will logically

help Support Coordinators better understand what that person’s preferences actually are. If

the Support Coordinator makes these efforts to know and understand what the individual

wants, understands the individual’s communication style, and listens to feedback and

suggestions, it is more likely a desired and appropriate work environment will be secured.

Recommendations

It has been shown through this study that having Supported Employment is related to lower

costs and improved individual outcomes. Knowing the individual well, understanding the

individual’s strengths, goals, interests and communication style are key to helping ensure

individuals receive this service, matching strengths and interests to appropriate employment

options. Knowing and understanding how to offer individuals informed choice and introducing

them to different places and opportunities to work in the community will help people move

toward work in integrated environments. This service appears to be more economical to

Georgia while at the same time improves many outcomes for individuals, including more

contact with community activities where they can build stronger relationships with friends and

natural supports, which in turn strengthens safety and health outcomes.



Over the past several years, DBHDD has shown its commitment to employment for individuals

with IDD by becoming a member of the Supported Employment Leadership Network (SELN) and

an Employment First state. Being an Employment First state means that DBHDD is committed

to employment being the first and preferred option for paid services for individuals with

disabilities. DBHDD developed a Memorandum of Understanding (MOU) with the Georgia

Vocational Rehabilitation Agency (GVRA) to contract with providers to complete assessments

and job development with individuals. Most recently, DBHDD has contracted with WISE, a

company out of the State of Washington to provide technical assistance and training to

stakeholders to help build the network’s capacity to facilitate Supported Employment in

community businesses. These continued efforts and considering the recommendations below

could strengthen DBHDD’s Supported Employment goals for individuals with IDD.

Recommendation 1: The Collaborative could use specific findings from this study to design a

training session that would help Support Coordinators better support individuals by offering

informed choices related to competitive work. The training should help staff understand what

good documentation in these areas looks like, such as the full meaning of informed choice and

exploring various ways for it to be offered.

Recommendation 2: Documentation is often a reflection of the degree to which providers and

Support Coordinators understand and implement concepts such as informed choice and

integrated employment. In this study, Support Coordinators with better documentation show

how they support the individual with education and opportunities for integrated employment,

discuss options with the individual, and support the individual’s personal strengths and

preferences and thus, were more likely to serve individuals who had Supported Employment.

Therefore, DHBDD and the Collaborative may want to consider providing more training to

Support Coordinators on how to offer options and education related to community

employment and person centered practices. If developed, this should include topics of

informed choice and how to develop customized employment, which would then be reflected

in the quality of their documentation.

Recommendation 3: DBHDD should continue to work with the Supported Employment

Leadership Network (SELN) and WISE to help improve employment related staff competencies.

Recommendation 4: Improving social roles and community connections can directly enhance

an individual’s ability to learn about and find community employment. Therefore, DBHDD may



want to consider strengthening language in the provider manual requiring better education and

informed decision-making about social roles and community connections for people receiving

services. Also, it is recommended that providers and Support Coordinators be required to take

annual training on how to develop community connections and social roles.

Other Findings

In addition to the key findings from the research questions, some other results from the

analyses are of interest. Controlling for all variables in the models, the following results were

also significant: receiving Community Access at the individual level is positively associated with

having Supported Employment; however, individuals receiving Community Access in a group

were half as likely to have Supported Employment; and the group format is more expensive per

capita. In addition, compared with women, men were more likely to have Supported

Employment, and individuals living in their own homes were more likely to have Supported

Employment than those living in group or host homes.

Recommendation 5: Most people might agree a personal home is better than a group home

environment. Since CRA is the most expensive service offered through the HCBS waiver, the

Collaborative could work with a stakeholder workgroup to help determine barriers to

affordable housing for people with disabilities and how to advocate for more options that are

not as expensive as group home living. Increasing Supported Employment and the individual’s

income would help toward that end as well.

Recommendation 6: The Community Access Individual service supports people to develop

skills promoting independence in the community. Because this service is closely linked to

employment, it is recommended DBHDD could consider an addition to the program description

to include supporting individuals to explore community employment.

Summary

DBHDD requested a study to determine if a broad understanding of the benefits of receiving

Supported Employment could be tested for statistical significance. Is it less expensive and does

it improve individuals’ outcomes? Having significant findings of reduced cost and improved

outcomes, as shown in this study, can lend support to the state’s efforts to generate specific

policy and quality improvement initiatives designed to improve the service delivery system and

outcomes for people with IDD receiving services through the HCBS waivers.



Appendix 1: Support Coordinator Record Review Expectations

Community Life: Integrated Employment

Documentation demonstrates opportunities to seek employment and work in competitive integrated settings and/or higher education.

Documentation demonstrates the Support Coordinator has reviewed and discussed opportunities for supported employment with the person.

Support Coordinator advocates for and ensuring the opportunity to actively participate in community activities and types of employment the same as citizens without disabilities. (D.III.4b)

Person Centered Practices: Person’s Preferences

Documentation reflects communication style.

Documentation reflects strengths.

Documentation demonstrates the person is working on goals that matter most.

Documentation demonstrates the support coordinator has an effective means of soliciting and/or addressing feedback from people receiving services, i.e., monthly/ quarterly discussion.



Appendix 2: Regression Results

SCRR Logistic Regression Table: FOAs30

Table 10. Odds Ratios for Supported Employment by SCRR Scores (FOA)

July 2015 - June 2018 (N = 1,236)




SCRR FOA ORs (1 = ≥75%) 1.11 1.06 2.46** 1.02 0.63*

Age 0.98 0.98 0.98 0.98 0.98

Gender ( 1= Male; 0 = Female) 1.61* 1.60* 1.62* 1.60* 1.59*

Race (1 = White; 0 = All other races) 0.78 0.78 0.78 0.78 0.81

Waiver Type (1 = COMP; 0 = NOW) 0.69 0.69 0.73 0.69 0.69

Severity (1 = Profound/Severe) 0.27* 0.27* 0.28* 0.27* 0.27*

HRST Medium Risk vs. Low Risk 0.47 0.47 0.49 0.47 0.47

HRST High Risk vs. Low Risk 0.49 0.49 0.51 0.49 0.50

Own Place vs. Group/Host Home 3.14* 3.12* 2.64* 3.17* 3.65*

With Parents vs. Group/Host Home 0.86 0.86 0.80 0.86 1.02

Community Access Group 0.48* 0.48* 0.52* 0.48* 0.46*

Community Access Individual 1.54 1.55 1.54 1.55 1.57

Community Living Supports 0.71 0.72 0.68 0.72 0.72

Prevocational 0.51*** 0.51*** 0.47*** 0.52*** 0.57***

Other Services 0.21 0.21 0.22 0.21 0.22

SCRR Logistic Regression Tables: Expectations from EFA

Table 11. Odds Ratios for Supported Employment by SCRR Expectation:

Choice and Community Life

July 2015 - June 2018 (N = 1,236)

Dependent Variable: Supported Employment Choice Community Life

Explanatory (Independent) Variables

Services and Home

Life Community/ Employment

Community Integration

Integrated Employment

Expectation ORs (1 = ≥75%) 0.95 1.28 1.29 4.42**** Age 0.98 0.98 0.98 0.98 Gender ( 1= Male; 0 = Female) 1.59* 1.61* 1.62* 1.62* Race (1 = White; 0 = All other races) 0.78 0.79 0.78 0.74

30 Throughout the Appendix, * = p<.05; ** = p<.001; *** = p≤.0001.




Choice and Community Life

July 2015 - June 2018 (N = 1,236)

Dependent Variable: Supported Employment Choice Community Life


Services and Home

Life Community/ Employment

Community Integration

Integrated Employment

Waiver Type (1 = COMP; 0 = NOW) 0.68 0.71 0.70 0.74 Severity (1 = Profound/Severe) 0.27* 0.27* 0.27* 0.27*

HRST Moderate Risk vs. Low Risk 0.46 0.47 0.47 0.49

HRST High Risk vs. Low Risk 0.49 0.49 0.49 0.51

Own Place vs. Group/Host Home 3.21* 3.10* 3.08* 3.33* With Parents vs. Group/Host Home 0.86 0.84 0.87 0.99 Community Access Group 0.48* 0.48* 0.49 0.53 Community Access Individual 1.55 1.55 1.51 1.43 Community Living Supports 0.72 0.70 0.70 0.71 Prevocational 0.52*** 0.49*** 0.51*** 0.61***

Other Services 0.21 0.21 0.22 0.21



July 2015 - June 2018 (N = 1,236)

Dependent Variable: Supported Employment Person Centered Practices


Person's Preferences

Monitoring S&S31

Evaluation/ Modification

S&S

Implementation/Needed Changes

Response to

S&S

Expectation OR 2.28* 0.86 1.20 1.26 1.17 Age 0.99 0.98 0.98 0.98 0.98 Gender ( 1= Male) 1.63* 1.60* 1.60* 1.62* 1.60* Race (1 = White) 0.77 0.78 0.79 0.77 0.78 Waiver Type (1 = COMP) 0.70 0.69 0.71 0.69 0.69 Severity (1 = Profound/Severe) 0.27* 0.27* 0.27* 0.27* 0.27* HRST Moderate Risk vs. Low Risk 0.48 0.47 0.47 0.47 0.46 HRST High Risk vs. Low Risk 0.49 0.49 0.48 0.51 0.49 Own Place vs. Group/Host Home 2.93* 3.17* 3.10* 3.10* 3.11*

31 S&S = Services and Supports





July 2015 - June 2018 (N = 1,236)

Dependent Variable: Supported Employment Person Centered Practices


Person's Preferences

Monitoring S&S31

Evaluation/ Modification

S&S

Implementation/Needed Changes

Response to

S&S With Parents vs. Group/Host Home 0.85 0.86 0.85 0.86 0.85 Community Access Group 0.47* 0.48* 0.48* 0.48* 0.48* Community Access Individual 1.56 1.55 1.54 1.55 1.56 Community Living Supports 0.71 0.72 0.70 0.71 0.71

Prevocational 0.49*** 0.52*** 0.50*** 0.51*** 0.51**

* Other Services 0.22 0.21 0.21 0.22 0.21

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