Since the creation of Minnesota’s home and community-based services (HCBS) waiver system, Minnesota’s Department of Human Services (DHS) and providers have been working together to ensure older adults and people with disabilities have access to the highest-quality services in every community. Providers like you play an important role in making sure people make their own choices and pursue their desired opportunities, contribute to their communities and are treated with dignity and respect.
The HCBS provider toolkit contains frequently asked questions, guidance and examples of provider practices that support choice and autonomy for people who receive HCBS.
New: In addition to the toolkit, DHS created three short videos to highlight providers that are doing excellent work to ensure their services are person-centered, that people have opportunities to engage in their communities and they are supporting people to have the highest possible quality of life. Watch a video trailer here (with captions) | Audio-described version
The videos can be found below under the “how can I learn more about…” questions under the Person-centered practices, Community engagement and Employment topics.
We encourage providers to use this toolkit and promising practice videos to help them generate ideas on how we can all better serve older adults and people with disabilities.
Note: In the questions and promising practices below, “we” refers to HCBS providers and “people” or “person” refers to people who receive Medicaid HCBS waiver services. The term “home” refers to HCBS provider residential settings where people who receive Medicaid HCBS waiver services live and call home.
Person-centered practices are support- and service-planning practices that are not driven by professional opinion or limited service options. Instead, planning looks at services and supports in the context of what it takes for a person to have the life he or she wants. The person, along with his or her support team, identifies effective support and services that will help the person live, learn, work and participate in preferred communities on his or her own terms.
We use person-centered practices because they increase people’s quality of life and help them to create or maintain a life they enjoy in the community. Person-centered practices are flexible and adaptable and encourage informed choice and creativity.
Promising practices from HCBS providers
Supporting people’s choices in activities
Miguel has shown little interest in participating in group activities and often becomes frustrated. His support team used person-centered planning to identify what is important to him. The support team talked with Miguel about how he seems happiest sitting by the front door to watch people coming and going from his home. Staff began having Miguel help with tours to create a meaningful activity related to this preference. Over the past year, Miguel has enjoyed becoming a greeter and assisting with tours of his home.
Supporting people’s preferred daily schedules
The people we support do not all eat lunch at the same time. Elka picks when and with whom she wants to eat, allowing her to socialize with different friends throughout the week. George, on the other hand, likes to eat early and without distractions or others in the room. Liza prefers eating later or sometimes not at all, so she is offered food or snacks throughout the day. Christian requires assistance with his meals and likes having a choice in who will assist him, which varies daily. We also work with people to schedule appointments and other service plan tasks around their personal schedules and preferences.
Supporting people’s choice in services
As Kacey was moving into a new home, she was assessed to need physical therapy, which is a service option provided at her home. Even though receiving physical therapy at home was an option, Kacey chose to continue seeing the physical therapist she had been seeing before she moved. Kacey’s provider assists her with transportation to get to her weekly physical therapy appointments.
Supporting people’s interests
Darius is very interested in U.S. presidential history and can name all presidents and the years they served. President George H.W. Bush passed away on Nov. 30, 2018, and Darius expressed interest in attending his funeral. Darius and his staff determined that it was not feasible to attend the funeral in person and explored other options. Darius was able to attend the funeral virtually and watch on an iPad. Darius and his team are exploring ways to engage in other meaningful activities that support his interest in U.S. presidential history.
Theo started an exercise routine years ago, using home exercise equipment. After a couple of years of this routine, he expressed an interest in joining a fitness center. We helped Theo to gather gym information, tour local fitness clubs and find out fees associated with each. With that information, Theo made the decision to join the YMCA. He now has his own membership, and we help him with transportation and support to work out at least once per week. Since Theo joined the YMCA, four other people have also purchased memberships. We provide or arrange transportation for them weekly.
Providers can think in a more person-centered manner by recognizing the whole person, communicating the belief that everyone has gifts to share and maintaining a focus on the person.
Finding a balance between what is important to someone (e.g., what makes them happy) and what is important for someone (e.g., what keeps them safe) is the core concept of person-centered thinking.
Promising practices from HCBS providers
Understanding what is important to people
All people we support complete interest tracker surveys to help staff to create meaningful schedules that allow for choice and individual pursuits. We also use a reflection form to gather input on people’s experiences at specific destinations when they go out. The forms highlight what they liked or disliked about a destination and what accessibility challenges they might have experienced. These tracking forms assist staff greatly when working with people who are unable to communicate choice. We collect information from people, staff and community references to help us to offer a wide variety of activities at various community locations.
Assessing and supporting a person’s needs
We use an assessment process to identify community needs and preferences to include in people’s service plans. For example, during the assessment process, a person said they have anxiety when participating in large group shopping trips and prefer going on shopping trips alone or in small groups. To support this person’s needs, we plan weekly small group or individual shopping trips for people so they can access their community resources.
Creating opportunities to support people’s interests and preferences
A person we serve expressed an interest in photography, so we created opportunities for him to take pictures at home and during community activities. This interest eventually grew into a passion. He now goes out on photo shoots to connect with his local community. We also noticed that other people we support started having an increased interest in the arts, which led us to partner with two nonprofits to open a space for art creation and exhibition that is fully accessible and open to artists from all walks of life. This has been an amazing venue for community integration – it has resulted in many collaborative projects and exhibits between people and established artists in the community.
Informed choice is decision-making based on accurate and complete information. Informed choice happens through ongoing person-centered conversations and activities. A person making an informed choice understands the options – as well as the risks and benefits – in any given decision. With informed choice, community resources and supports are valued and explored.
The HCBS rule supports people’s rights to make informed choices and determine what is important to them and for them. Providers can ensure people have informed choice by:
Providing or helping people get information that allows them to exercise informed choice in creating their individualized plans when it comes to the selection of:
Outcomes
Providers
Supports and services
The most integrated settings in which the supports and services will be provided
Methods of getting services.
Putting in place policies that help them to provide supports and services and afford people meaningful choices.
Notifying people through appropriate methods of communication about opportunities to exercise informed choice, including the availability of support for people who need help to exercise informed choice.
Helping people exercise informed choice in making decisions.
Promising practices from HCBS providers
Choice of home, including non-disability-specific homes
Nina is ready to move into a new home, so she shares her housing preferences with her case manager. Nina and her case manager gather a list of possible homes that meet Nina’s needs based on her assessment and preferences. They schedule a time to visit Nina’s top three choices so Nina can meet the providers, see the homes and make an informed decision.
Choice of services
Many people benefit from engaging in community education sessions or activities put on by the greater community. One person in our adult day program was interested in learning more about Parkinson’s disease. Instead of inviting a community speaker to come to our center, we arranged for the person to attend a community Parkinson’s support group once per week. He was able to meet other community members who share his experience with Parkinson’s and discuss his concerns with others who understand what he is going through.
There are many techniques that can be used to help providers better learn about people’s preferences and needs. Some suggestions for making those opportunities more productive include:
Asking a person open-ended questions about choice, independence, individual rights, and community access and integration. Specific questions could range from, “What types of opportunities do you have to spend time in the community with other community members?” to “What types of interactions are common for you to have with members of your community?” Other things to ask include:
“What do you like about your work?”
“What do you like about your housing?”
“What do you like about your services?”
“What would you change about each of them, if anything?”
Other important questions are: “Have you felt like there are situations in which you haven’t been treated fairly? If that’s the case, can you describe them?”
Listening carefully to the person’s answers and following up on their responses. This can be done by seeking details and examples of how people’s services have supported or hindered the opportunities they would like to have to be integrated members of the community.
Observing the person while they answer questions to evaluate if body language or other signs suggest people’s true feelings are different from their words. It is helpful to reassure people that their answers will not be used against them, but instead to help improve services they or others receive.
Using visual aids or technology solutions such as photos or communication devices to learn the preferences of a person who is unable to verbalize his or her responses. For example, a staff member may show a person pictures of community activities and ask the person to select a preference and identify a friend who might want to come along.
Staff can have these structured conversations to learn more about people’s needs and preferences during their intake meeting, following up at future annual, semi-annual or support team meetings, during day-to-day interactions, and at regular one-on-one meetings.
Providers may also use a tool such as Planning Alternative Tomorrows with Hope (PATH), which is an eight-step process to identify a person’s dreams and then work backward to lay out steps to reach that goal. Through annual or semi-annual meetings, people and the staff supporting them can discuss what they would like to accomplish in the next year and beyond. After each meeting, a staff member can share the person’s dreams and passions with the people who work closely with him or her.
Promising practices from HCBS providers
Assessing interests and preferences
As they are moving in, people and their interdisciplinary care team members complete a formal interest and activities assessment. This assessment asks questions about their history and preferences in community activities, traveling, special events, active games and group activities. It also asks more open-ended questions about hobbies or other interests the person finds particularly valuable or motivating. Then we review the assessment at regular intervals and talk about any areas where people’s interests and preferences have changed over time. We can use this information about new preferences to plan upcoming activities.
We record a snapshot of individual preferences, interests and needs on a person’s One Page Profile. This one-page summary is shared with key team members who work with the person. We use it as a reference point in one-to-one biweekly conversations and individualized planning between support staff and the person. The questionnaire focuses on identifying people’s preferences for their employment schedule, frequency of community engagement and what specific actions of support occurred over the past six months to help them explore any interests identified in the previous evaluation. We then review the information with the person and the support staff and adjust strategies as needed to increase success.
We complete a “Satisfaction Inventory” (or other similar survey tool) annually with all people we support. In this survey, people list their favorite and least-favorite activities, suggest activities we are not already providing, let us know their preference for in-house or community-based activities and indicate if they want to work or not. We use these preferences to design activities and events throughout the year. Staff are also encouraged to explore people’s preferences informally during day-to-day interactions and adjust planned activities accordingly.
Listening for informal requests and stated interests
Moira was sitting outside enjoying a nice afternoon, and asked one of our support staff members walking past if she could camp in the yard. Moira did not have a tent, but the staff member asked around our team and found one to borrow. Moira and the staff member planned the campout together to accommodate for some medical issues, and they were able to make the impromptu camping trip happen for her. Moira later found a used tent online that she liked and purchased, and our team is now working with her to find other opportunities for her to camp that support this interest and promote community inclusion. One potential option is an upcoming event at a nearby state park.
Asking friends and family
After asking for consent from the person, we explore the activities and community engagements a person likes and dislikes taking part in with their guardian, family members or friends. In one such case, we discovered that a person loved to go fishing. So, for the past few years, we have hired a local angler to take the person and others fishing in a pontoon boat a couple of times each year.
Hosting group discussions about interests and preferences
At least monthly, people gather in groups to express any community and activity interests for the following month. Staff bring community calendars to this meeting so people can get ideas about the activities that are going on in the community.
Getting feedback on past activities
People and staff hold “Monday Morning Meetings” on a weekly basis to discuss activities. They talk about last week’s activities, what they enjoyed, what they didn’t, what the schedule is for the week ahead and opportunities in the community that might be available in the evenings or on weekends. During this meeting, the presider always asks, “Can you think of anything you would like to do this week or in the weeks ahead?”
Learning about people as individuals
People we support have created a “Get to Know Me” Hall of Fame. This is a hallway where people post pictures, share their interests, provide updates on activities they have engaged in and share ideas (Note: This was created by people themselves, but we ensure full confidentiality as directed and desired by each person and get appropriate releases if a person wishes to share information).
Using nonverbal communication tools
When a person has limited or no verbal communication, staff use numerous methods to ensure people have a choice. Our computers have touch screens and software for assisting with communication. We also use iPads, picture schedules, Picture Exchange Communication System (PECS) and a large interactive touch-screen board to help people to communicate their choices. Staff encourage people to use their communication devices to share their ideas about what they would like to do in the greater community.
This webpage from the Council on Quality and Leadership helps people understand the HCBS rule through videos, documents and other resources. Resources from the Council on Quality and Leadership are written for people with disabilities; however, the content may be applied to older adults, as well.
This Council on Quality and Leadership resource, Your Right to a Community Life (PDF), helps people to think about their services and prepare to advocate for themselves. Step 2 includes questions that people may answer to help think about services and whether services are providing choice, individual rights, independence and opportunities for integration in and access to the community.
This presentation from a DHS long-term services and supports improvement tool training (PDF) provides an evaluation tool that can help providers improve their person-centered practices. The slides include sets of questions that can be used to evaluate a person’s experience with his or her coordinated services and supports plan (CSSP) and service provider (pages 31-51). The slides also provide an overview of the data-collection tool and suggestions for how to collect this data (pages 5-29).
DirectCourse’s 3.9-hour person-centered planning class includes four lessons: Foundations of Person-Centered Planning; An Overview of Person-Centered Approaches; The Person-Centered Planning Process; and Bringing Person-Centered Plans to Life. The College of Direct Support courses are written for support staff who work with people with disabilities; however, the content can also be adapted for working with older adults.
This DHS guide to encouraging informed choice and discussing risk helps providers to perform support planning (creating person-centered support plans with people), specifically when and how to discuss people’s rights and ability to make informed choices that may include risk. The guide includes helpful information in the following sections:
The Background section describes how person-centered practices contribute to living a high quality life and link to further resources on person-centered practices.
The Definitions section includes a definition of informed choice.
The Conversation guide describes how to have discussions on risk and encourage informed choice at any point during service delivery. It also describes the support planner’s role.
These 10 DHS videos on an Introduction and Guide to Supported Decision Making, which range from 3 to 11 minutes long, can help you learn more about supportive decision-making in the person-centered planning process, with themes of self-determination and supporting people in retaining their rights.
The Positive Supports Minnesota webpage explains what it means to be person-centered, including person-centered practices and person-centered planning. Then the Person-Centered Planning Methods section identifies common outcomes of person-centered planning processes and provides examples of specific person-centered planning methods.
These examples of person-centered planning and community living from Positive Supports Minnesota are success stories of using person-centered tools to support people in community living. “Katie’s Story” is an approximately 2-minute video describing how person-centered planning affected her life. “Cliff’s Story” is an article describing how person-centered planning helped Cliff to find housing that suited his preferences and quality of life.
This comprehensive DHS webpage on person-centered practices includes a summary of what a person-centered support system is like, as well as answers to common questions about person-centered practices.
This person-centered training information describes University of Minnesota/DHS training for providers, lead agency staff and others on person-centered practices. The training has three parts, the descriptions of which are all helpful: being person-centered: an introduction; person-centered thinking; and person-centered planning.
This Positive Supports Minnesota person-centered practices overview explains tools, planning and organizational changes for person-centered practices. It also links to examples of person-centered practices in different settings and with different populations (e.g., mental health, aging, community living, employment).
People have the right to person-centered service planning, conflict-free case management and settings that have characteristics that are home and community-based. More specifically, through setting supports, people have the right to:
Seek employment and work in competitive, integrated settings
Engage in community life
Control their personal resources
Receive services in the community with the same degree of access as people
who do not receive HCBS services
Choose their setting from available options
Privacy, dignity and respect
Freedom from coercion and restraint
Optimized individual initiative, autonomy and independence in making life
choices, including in setting a daily schedule and choosing with whom to interact
Choose services and supports and who provides them.
Provider-owned and -controlled residential settings must meet additional standards. People in these settings also have the right to:
A lease or other legally enforceable agreement
Privacy in their bedroom or living unit, including lockable doors
The choice of roommates (if in a shared unit)
Freedom to furnish and decorate their unit
Freedom and support to control their schedule and activities, including access to food at any time
Freedom to have visitors at any time
Physical accessibility.
Promising practices from HCBS providers
Supporting visitors
People are always welcome to have guests in their home. Guests may eat with a person free of charge and stay overnight. For example, one person’s minor son spent many overnights with his parent at her home. They often went to the movie theater together when he stayed. We supplied the movie tickets and transportation on such outings in the community.
Tonya’s friend Belle likes to stop by to visit when she is in the area. Tonya’s home allows visitors at any time. If Belle visits after a certain time and the doors to Tonya’s home are locked, Belle must use the doorbell and sign in and out on the visitor log by the front door. If Belle comes to visit and other people are sleeping, we expect Belle to be quiet and respectful of all people who live in the home.
Ensuring privacy
Michelle has many friends all over the world with whom she likes to keep in contact via text, email and social media. Michelle uses her cell phone or computer to communicate daily with her friends and family without having to have staff present.
Nicolai has a seizure disorder that requires frequent checks. Nicolai’s person-centered plan clearly instructs staff to knock on his door before entering to allow privacy, except during sleep times. The plan maximizes Nicolai’s right to privacy while supporting his health need for uninterrupted sleep.
People have the right to know their rights and to have their rights explained to them in a way they understand. Explaining people’s rights in a variety of ways will help to promote understanding. Here are some strategies for talking with people about their rights:
Meet with each person you serve in person and individually to talk about his or her rights.
Find a good place to meet and have this discussion. Minimize any distractions.
Ask open-ended questions that cannot be simply answered by “yes” or “no.” This will allow you to learn more about how a person is understanding his or her rights.
Take your time, and don’t rush communication. Give people time to think about what they are hearing.
Use examples, photos, pictures or role playing to make the information more understandable.
Promising practices from HCBS providers
Explaining people’s rights under a lease in a way they can easily understand
We explain the terms of our lease/agreement in a format that people can easily understand. For example, we met with Sonam and her case manager to review the terms of her lease/agreement, including her rights and responsibilities, before Sonam moved in so she could make an informed decision about where she wanted to live. To make sure that Sonam understood the terms of the lease/agreement, we gave one or more examples for each part of the lease/agreement, then paused to discuss Sonam’s questions. To talk about Sonam’s right to decorate her room, we explained how other people decorated their rooms and provided some additional decorating options. Then, we talked about what types of decorations Sonam might be interested in. We followed this pattern for each major component of the lease/agreement to be sure Sonam fully understood her rights and had ample opportunity to ask questions.
Using handbooks and other documentation
We have a group meeting once per year to give people an opportunity to review and discuss our program handbook, which explains the intention of the program and people’s rights. People who have been with us longer and have attended many of these meetings know the handbook quite well and enjoy taking the lead in describing parts of the handbook to the group, with staff members there to support and fill in or correct details as needed. This creates a fun and engaged energy and gets newer people excited to learn about their rights. Two of the rights outlined and explained are people’s right to participate in developing their own care plan and the right to plan their activities.
The role of direct care staff in supporting people to express their rights is to ensure that they know and understand their rights. This can be done through formal teaching, such as individually organized training sessions (e.g., role playing, small group activities) and through teachable moments, such as witnessing and learning from another person who is expressing his or her rights.
Promising practices from HCBS providers
Encouraging visitors
Program staff promote the right, as well as the expectation, of “freedom of association” for people. For example, program staff encourage people to invite their friends, family and team members to visit, then encourage people to provide tours of the various jobs and activities at their home when they have visitors.
Expressing rights
During a monthly resident council meeting, Amira talked about limited access to the fitness center, expressing concerns that every time she would like to use the treadmill, the fitness center is locked. Other people noted that they have experienced the same thing. The resident council said they would like to have their own keys to the fitness center instead of relying on staff to provide access at their convenience. People brought this concern to staff, who are now working on getting key fob access for the fitness center so that everyone can enjoy it when they choose.
See the below resources for more information on rights.
This article from The Council on Quality and Leadership helps people understand the HCBS rule through videos, documents and other resources. Resources from the Council on Quality and Leadership are written for people with disabilities; however, the content can be applied to older adults, as well.
This approximately 5-minute Council on Quality and Leadership video, What does the Rule Guarantee?, is directed toward people who receive HCBS services. It provides an overview of how providers must treat them the same as any other person, that services are to be tailored to each person and that people have the rights to privacy, dignity, freedom from coercion and freedom from restraint.
Restrictions can only be put into place to keep people safe. This approximately 4-minute video on Rights Restrictions and Modifications, from The Council on Quality and Leadership, explains what scenarios make restriction necessary, what providers must do before putting a restriction in place and the rights people have while under a restriction.
This approximately 5-minute Council on Quality and Leadership video features people who receive HCBS waivers explaining the benefits of HCBS settings rules.
This Council on Quality and Leadership resource, Your Right to a Community Life (PDF), helps people to think about their services and prepare to advocate for themselves. Step 2 includes questions that people may answer to help think about services and whether services are providing choice, individual rights, independence and opportunities for integration in and access to the community.
DirectCourse’s 3.6-hour Individual Rights and Choice class includes four lessons: Overview of Individual Rights; Restrictions of Individual Rights; Overcoming a Past of Barriers, a Future of Risks, Choices and Solutions; and Your Role in Supporting Expression of Rights and Facilitating Choice. The College of Direct Support courses are written for support staff who work with people with disabilities; however, the content can also be adapted for working with older adults.
This DHS FAQ provides information on rights modifications to the HCBS settings rules.
This orientation manual for direct support professionals and supervisors (PDF) from the Virginia Division of Developmental Services helps you think about and interact with people with disabilities in the same way you do with people who do not have disabilities. This resource is written for people with disabilities; however, the content can be applied to older adults, as well. Specifically, pages 1-22 are helpful.
These 10 DHS videos on an Introduction and Guide to Supported Decision Making, which range from 3 to 11 minutes in length, provide information on supportive decision-making as “an approach for reducing the need for restrictive proceedings where an individual's right to make choices is taken away.”
My Rights workbook videos: Is it your responsibility to go over rights with the people you support? Do you need to make sure your staff are advocating for people’s rights? Are you ensuring people are exercising their rights? Through this video, we will explore ideas on how to explain rights in a way that people can understand using a newly developed Rights Workbook. Join us as we help you to increase your knowledge so you can empower the people you support to put their rights into action. Part 1, Part 2, Part 3 | Video training course: Rights - Understood, Advocated, and Exercised!
Many people need more opportunities to be active community members who are included alongside their neighbors. Integration is important because it means that a person with disabilities has opportunities to be an included member of his or her community like someone who doesn’t have disabilities.
HCBS settings must:
Be selected by a person from choices that include settings not solely limited to people who have similar or the same disabilities
Be integrated into the larger community and support access to it
Offer individuals opportunities to work in integrated settings, control their personal resources and engage in life in their communities.
Engaging in the community may range from finding competitive employment to participating in activities in the community. Other examples include obtaining community services and going to places where other community members spend time, such as businesses, restaurants, the library or the gym. People could also take a class or tour, go to a place of worship, attend a sporting event, go to a concert or play, see a movie, spend time shopping, get involved in a club or a hobby, visit a county fair or the beach or go to a party or dance.
Promising practices from HCBS providers
Involve people in planning and choosing community activities
People we support sign up for activities they want to do, including shopping trips, movies, music, walks, the zoo, nature centers and community events. Staff typically provide transportation, if needed, and support, if requested.
To plan activities, our activities director regularly meets with people in groups and individually to hear about what community activities they would like to do. We try to encourage people to participate in activities outside their home – like going to the local movie theater. We purchase movie passes for people who cannot afford them and make sure the passes are readily available. We also provide transportation. In addition, we schedule at least one group shopping trip each week to a city at least 30 miles away. Staff go on the shopping trip to assist people as needed. We post in our lobby a monthly calendar of activities and keep it continuously updated. We also put the monthly calendar in various places around the building and have extras for people to take with them. Additionally, we post the calendar on our website and Facebook and keep it updated with any changes. We have the daily schedule written on a large chalkboard in the lobby.
Creating individual plans with people
Staff members work with people to plan community activities throughout each month depending on what people want to do. People are encouraged to express their interests and explore community activities that they may enjoy, either by themselves or as a group.
Fawzia enjoys playing volleyball as one of her preferred activities. Fawzia does not require constant supervision. Her support plan documents that Fawzia is able to walk independently to a nearby community center to join in an open volleyball session. During the session, she has an opportunity to play and interact with other community members.
Taking advantage of what is already happening in the community
A wide variety of activities, events and places exist for people to spend time in the community, including:
Arts: art lessons, community theater, concerts, exhibits, festivals, galleries, museums, plays, putting on plays or performances, shows and sales of original art, and teaching art in schools.
Community events: celebrations, clubs, community centers, community education classes, county fairs and festivals, faith events and services, fire station tours, information sessions, meet and greets, parades, senior centers and volunteering.
Entertainment: amusement parks, book clubs, bowling, circuses, dances, libraries, lunch at the corner shop, movies, parties, shopping trips, and sporting events including community, high school, minor league and professional events.
Exercise: bicycling, billiards, chores, golf, gym and exercise classes, mall walks, outdoor games, park walks and roller-skating.
Outdoors: apple orchards, boating, beaches, camping, community gardens, dock fishing, dog parks, farms and farm tours, hikes, nature centers, picnics, petting zoos and public pools.
Routine activities and errands: banks, beauty shops, clinics, coffee shops, convenience stores, doctor’s offices, drug stores, grocery stores, guitar stores, pet stores or animal shelters, post offices and shopping malls.
Dedicating staff time to coordinating community activities
We have an activities director who works with people to learn about their interests and then coordinates community activities. She distributes a monthly activity schedule, which outlines a variety of activities in the community offered several times a week. People can then sign up for activities ahead of time or join last minute if there are still openings available. We either provide or coordinate transportation, or people can use public or supported transportation options.
Providing individualized supports for community integration
Every year, people take a trip to the county fair. We help people invite their family members or natural supports to join our group, which also includes several staff members. We provide transportation to the fair and make sure everyone knows when and where they will be picked up. We help people pursue their own interests and activities at the fair by ensuring that people or small groups are paired with natural supports or staff, as needed.
Cai played guitar in a band for 25 years before the car accident that caused his brain injury. He missed meeting his friends every Friday at the local pub for live music. Cai, his provider and his case manager came to an agreement that includes a safety plan that supports Cai to see his friends at the pub on Friday nights. Cai’s person-centered plan includes text messaging the provider at scheduled intervals to say he is fine or to request support, returning to his home by an agreed upon time and planning transportation options to and from the pub.
Providers have many options to partner with other groups to expand community engagement opportunities for the people they are serving. For example, employment services organizations can help older adults to stay active in the community or help people to find work that matches their skills and interests. Such organizations can also help people to strengthen their relationships with their colleagues outside of work tasks. This can be accomplished by ensuring people are engaged in “social” activities at work such as breaks, lunches or potlucks and involved in after-work gatherings such as barbecues or happy hours.
Looking beyond work, clubs or groups – both formal and informal – can provide opportunities for people to gather regularly, take part in meetings and engage in social activities such as group parties or coffee gatherings. Providers can help identify formal groups, such as a Rotary Club, by looking up different community service organizations, checking lists of groups posted at city hall or the chamber of commerce, or asking staff members about organizations their family and friends have joined. Most groups will welcome new people. Informal groups such as quilting clubs, walking clubs and card clubs can be located by checking in community centers and houses of worship or by asking others.
Providers can also find ways to help people engage in the community by partnering with organizations that need volunteers. Volunteering can be an opportunity for people to contribute and meet other members of the community.
Promising practices from HCBS providers
Partnering with organizations that align with people’s interests
Being a city block away from the high school gymnasium helps people access high school sporting events that they are interested in. We have an arrangement with the high school to allow people to receive a free access voucher to all sporting events.
We facilitate opportunities for people to create, display and sell artwork in the larger community. Last year, two people participated in an art exhibit at the local community center and received an award for their work. This award caught the attention of the local media: A reporter visited to interview them about their artwork and they were featured in a short article in the local newspaper.
Partnering with organizations for volunteer opportunities
We have ongoing opportunities available, particularly around volunteerism. People can choose what types of volunteer opportunities they would like to participate in based on their skills and interests. We currently have partnerships with 10 organizations that provide community volunteer opportunities: two senior living centers, a thrift store, a food shelf, an animal shelter, a home-to-home assistance program, a new home building program, a food drive, a hospital and a transitional housing program for individuals in recovery.
One person we support loves interacting with children. Living across the street from an elementary school has provided an opportunity to schedule weekly volunteer shifts in the school library to assist children in checking out books.
We have opportunities for people to partner with professional artists at the community center on a weekly basis. All are welcome to participate, but they have the choice.
Creating community projects
We have a monthly group meeting where people can brainstorm with staff to create community projects. At a recent meeting, one person mentioned that it was suicide prevention week, which sparked broader interest. After some discussion, the group decided to start a community-based campaign of positive messages designed to encourage and inspire. The City Council approved the project. People we support led the effort and drew positive messages in chalk on the sidewalks downtown for the community to see. They interacted with community members to explain what we were doing and spoke with local business owners to spread the word. We teamed up with a suicide prevention program in the county, and the director had signs made for us. Our artwork and messages were on display for community members during a local community festival.
Developing meaningful relationships with community members is important for people to be happier, make friends and maintain their health and well-being. Providers can help people to grow meaningful friendships and relationships by identifying welcoming people and places in the community, networking to discover connections to them and then finding opportunities for people to work, volunteer or spend their time with others in the community. Some strategies include:
Identifying people’s existing relationships with community members that can be strengthened. People are likely to attend activities and events with community members who are already friendly with them. Those community members may be interested in drinking coffee with a person at work, having a visit or making a new friend.
Figuring out where community members interested in being a person’s friend can be found, ranging from formal volunteer programs to seeking out former staff to re-establish their relationships with people.
Finding places in the community where community members are involved in a person’s interests and then identifying providers’ connections to those places. For a person who likes cars, places to explore could be an auto parts store, car museum or rental agency. Staff could then think about their connections to community members in those areas and introduce people to them.
Identifying welcoming places in the community for people to spend time. These could be places in a person’s neighborhood, such as community centers, senior centers, VFWs or small businesses that are friendly and where locals gather. It is important to consider whether the person would feel comfortable there and the role he or she would have. For example, at a welcoming neighborhood pet store, a person could routinely visit to pet the animals. A favorite coffee shop could also turn into a place to regularly spend time.
Promising practices from HCBS providers
Establish long-term partnerships for relationship development
Our city has a program in which professional visual artists and performing artists spend three weeks each year at a school teaching children about visual arts and theater. We have formed a partnership with this program in which people who have strong interests in the arts can assist the professional artists in teaching the children.
We created an ongoing partnership with a senior center through which people we support go to visit with other community members biweekly. We worked with the senior center to identify shared interests among people participating. That allows everyone to spend quality time with a partner who was paired with them based on shared interests in activities that range from sports to music.
Building meaningful relationships in the community through long-term projects
We learned through a community bulletin that a community garden was being developed close by, so interested people participated in the community garden kick-off meeting. After getting some initial information and signing up to be gardeners, people went to farmers markets, garden stores and hardware stores to purchase items needed for the garden. Now, people go to the garden twice a week to plant and maintain the garden alongside other community members. People also enjoy staying after the work is done once a week for a barbecue lunch with other community members.
Seeking out volunteer opportunities
People we support engage in numerous volunteer activities each week, including newspaper delivery on Wednesdays and food delivery to older adults on the first and third Fridays of each month. These opportunities are available to everyone. The food delivery activity is highly interactive because people take time to visit with the older adults to whom they deliver meals. Some very special connections and ongoing friendships have been made this way.
Joining existing clubs and groups
Several people we support have joined a coffee club at a local café, where they meet twice a month to converse, build friendships and foster ongoing relationships with other community members.
Hosting events and inviting community members
A friendly relationship with our local fire department grew from the dedication of Verne, one of the people we support. After hearing news reports about several dangerous fires in the area, Verne brought up the idea of making beef stew for the fire department and got several other people excited about the idea. With the help of a staff member, the group sent an invitation to the fire department and made the beef stew. On the day planned, more than a dozen firefighters visited, enjoyed the stew, posed for photos, shared stories and named Verne an honorary firefighter. This one event has led to an ongoing relationship between the fire department and everyone we support. We decided to invite the department to the beef stew event annually. This also led to new community opportunities for people: The firefighters recently asked for help judging the department’s annual chili cook-off at the fire station. A large group of people attended, sampling five varieties of chili and voting for their favorite.
This manual, Friends: Connecting people with disabilities and community members (PDF), provides strategies and tips for providers to connect people with disabilities to community members and promote relationships. Specifically, Strategy 4 (pages 37-38) identifies associations and clubs; Strategy 5 (pages 39-40) identifies places in the community where people are engaging in activities of interest to the person being served; and pages 60-61 discuss employment and day program roles for supporting social relationships. This resource is written for people with disabilities, but the content can be adapted to older adults.
This Council on Quality and Leadership resource, Your Right to a Community Life (PDF), helps people to think about their services and prepare to advocate for themselves. This resource includes steps people can take to advocate for the community life they want. For example, Step 2 includes questions people can answer to help think about services and whether services are providing choice, individual rights, independence, and opportunities for integration and access to the community. Resources from the Council on Quality and Leadership are written for people with disabilities; however, the content can be applied to older adults, as well.
This approximately 5-minute Council on Quality and Leadership video, What does the Rule Guarantee?, is directed toward people who receive HCBS services. It provides an overview of how providers must treat them the same as any other person, that services are to be tailored to each person and that people have the rights to privacy, dignity, freedom from coercion and freedom from restraint.
This CMS FAQ on people who exhibit unsafe wandering or exit-seeking behavior (PDF) answers common questions about complying with HCBS requirements when serving people who may wander or seek exits unsafely, though most of the content can apply to anyone. This resource includes community integration requirements. Additionally, Answer 4 (pages 6-7) lists strategies and practices settings can use to support community integration in accordance with each peson’s person-centered plan.
DirectCourse’s 4.4-hour community inclusion class includes four lessons: the Direct Support Professional Role in Community Inclusion; Matching Community Resources with Individual Interests; Community Bridge-Building and Networking; and Natural Supports. The College of Direct Support courses are written for support staff who work with people with disabilities. However, the content can also be adapted for working with older adults.
This orientation manual for direct support professionals and supervisors (PDF) from the Virginia Division of Developmental Services helps you to think about and interact with people with disabilities in the same way you do with people who do not have disabilities. This resource is written for people with disabilities; however, the content can be applied to older adults, as well. Specifically, pages 1-22 are helpful.
Waiver transportation providers including taxis, van services and volunteer drivers offer options for people to access their communities and lead fulfilling and productive lives. Resources for transportation services can be found at minnesotahelp.info. Further information about key agencies and organizations that provide waiver transportation in Minnesota can be found in Appendix A: Agency and organization overview on pages 94-96 of this Legislative Report (PDF).
In areas where public transportation is scarce, providers may also work with their local waiver transportation agency or county government to explore potential grant funding or regional partnerships that might be created. Searching out area volunteer driver programs or creating a new one by engaging family, friends and staff is an option for providers seeking to expand transportation opportunities. Depending on the situation, providers might also take other approaches, such as partnering with nearby agencies to rideshare, creating a bicycle-sharing program or asking community members to carpool to community events or activities.
Promising practices from HCBS providers
Transportation in rural areas
Transportation to community events and activities can be limited in a rural area. Some providers have purchased their own accessible vehicles. Some providers have used grant funding or volunteer drivers. And some have rented vehicles to increase options for community participation. Where available, providers also use public transportation and bus routes to access community events, as well as agency vehicles, Uber and Lyft.
Partnering with volunteers and community organizations
People we support live only blocks from a volunteer-based transportation service. Our appointment scheduling staff helps people to arrange rides through this service for community activities and events.
Using bicycles and apps
Using natural supports, Travis enjoys playing disc golf at a local course and has made several friends while playing rounds in the summer. Travis uses a wayfinding app on his phone to navigate and an adapted bicycle to play at local courses. The bicycle is adapted to include special handbrakes, a cargo area to carry multiple discs and a way to securely hold a GPS-enabled device to safely use the wayfinding app. Travis has made friends through his disc golf hobby. When they play at courses farther from home, Travis’ friends coordinate transportation together.
It is important to use person-centered practices to identify how to clearly communicate the transportation options available to people. Those options should be explained:
In language people understand: Providers can learn about language that people best understand by taking a person-centered approach, including asking questions and listening carefully to the responses.
In formats people prefer: Providers may use a wide variety of formats to communicate transportation options after identifying the preferences of the people they are supporting. Some examples include posting transportation schedules and having them available for people to carry with them, putting up flyers listing transportation options on bulletin boards, or discussing options for transportation with people individually or during meetings and other gatherings.
With the frequency people like: After first introducing people to all the transportation options available to them, providers may return to those discussions with the frequency that people prefer. It is helpful to remember that people’s activities and preferences evolve with time, so providers may expect that preferences about the frequency people would like review transportation options may change, too.
Providers have a variety of ways to offer support for using transportation options customized to a person’s needs and preferences, understanding that both might change with time. In day-to-day situations, providers may support people in using transportation options by:
Asking people if they have transportation arranged for any upcoming outings scheduled.
Discussing transportation options with a person and asking if he or she knows about all the options available or if he or she is just familiar with the ones used frequently.
Working directly with a person to figure out transportation, including how to request a ride, use a ride-hailing app, read the bus schedule or find it online, and locate the correct stop.
Helping a person to learn a new type of transportation. For example, a person could learn how to take the bus if he or she typically uses a transit service such as Metro Mobility. It might be helpful to develop tools or identify assistive technology (e.g. wayfinding apps) the person might use for support in navigating the community.
Providers may also provide additional support, such as connecting the person with someone who uses a new style of transportation (e.g., bike sharing, public transportation, ride-sharing apps) to discuss it or even try it out. Hosting sessions to show people how to research transportation options is another alternative.
Creating opportunities for people to come together to share rides and access the community together. For example, people might share a Lyft, Uber or taxi, or try a new bus route together.
Promising practices from HCBS providers
Supporting people in understanding and using public transportation
To ensure that people can access the community, our staff works directly with people to learn, build confidence in and access public bus routes. Staff also facilitates communication between people and the bus company to reduce barriers and establish any special accommodations, when needed.
Encouraging people to choose the transportation options that work best for them
Each person has options for transportation. We have a vanand there is public transportation in town for people to use to access the community. Many people also choose to walk downtown because they are only a short distance from parks, shopping and the library. Many people choose to use public transportation for their ride to work. Sometimes people use our van when they need to arrive home sooner or when they are connecting to another event that is time sensitive.
Providers can support people’s transportation needs by discussing options with their lead agency, such as grants, bus passes or local rideshare programs. Other options include advocating with local transportation services for preferable routes, seeking placement of bus stops or shelters closer to home and advocating for safer pedestrian navigation, walkability and alternative transportation options (e.g., bike paths) in their communities. Organizations could also choose to partner with other providers to advocate together for those changes or other policy priorities.
This Minnesota Council on Transportation Access report, Volunteer Driver Programs in Minnesota: Benefits and Barriers (PDF), explores the background of volunteer driver programs in Minnesota and discusses issues identified in using volunteer drivers. Appendix A (pages 17-20) lists transportation providers.
Federal rules require HCBS providers to support people’s full access to the community, including opportunities to pursue jobs and work in competitive, integrated settings.
To meet this requirement, providers must work with people and their support teams using person-centered thinking to make sure that people’s needs, desires and choice to work are evaluated. People must also be able to make choices through an informed process that includes real community experience to inform their decisions.
Residential and adult day service providers are required to support people in their choice to work; no barriers can be put in the way of people who choose to work. Such providers must offer flexible scheduling and activities that complement people’s employment schedules.
Some suggestions for providers include:
Bringing people, staff and management together to discuss opportunities, including work, volunteering and career development and exploration
Identifying employment resources, such as training or educational opportunities
Ensuring people know how to ask for support to seek employment
Documenting a person’s rights, including having a job, in a lease/residency agreement, if the person is supported in a home.
If a person decides not to pursue competitive employment, providers should:
Document the person’s experiences, reasoning and other information that resulted in the person’s informed choice not to seek employment at that time
Speak with the person to clearly address potential myths about working or barriers to employment
Help the person explore other opportunities of interest
Set up check-in conversations about the person’s level of interest in competitive, integrated employment during support team and service planning meetings.
Providers must, on an ongoing basis, offer the person opportunities to try new experiences. Providers’ policies should reflect that they are frequently checking with people about the chance to explore employment.
Promising practices from HCBS providers
Helping to develop employment opportunities
Staff works with people to develop career opportunities. For example, staff members who bring their children to a local day care are working with the owner to establish a helper position. The staff and day care owner are setting up standards for having a job there, including passing a background check, so that people can work at the day care weekly.
Dedicating staff time toward employment
Another way that we listen to people’s preferences is through our “Worker Representative Meetings.” These quarterly forums allow people to get together with staff and upper management to have their voices heard about such topics as employment opportunities, career exploration and development, volunteering and community integration in general. Notably, our business development manager is invited to each of these meetings, and he uses the information gathered there to drive the opportunities he seeks for career and employment exploration. Even though a person might not express a strong interest in employment, the opportunities that the business development manager makes available can widen the scope of the types of employment a person thought was available to him or her. It might help people to find interests they did not know they had.
Helping people apply for jobs and manage their benefits
We have a biweekly drop-in gathering during which people who are interested in employment can work together to apply for jobs on the computer or get help from two staff people who facilitate the sessions. This also is a time when people who have jobs can get help assessing and managing their benefits, either by working with our staff or getting a referral to a benefits specialist through Disability Hub MN.
Providing transportation services
Transportation is available for several people who work, bringing them to specific activities and helping to accommodate their schedules of choice.
Scheduling around people’s work schedules
Arnold has a part-time job. Arnold discusses his work schedule with his provider who schedules services and supports in a way that complement his schedule, including packing a lunch and medication that Arnold takes twice a day. Arnold does not get home until 7 p.m. from his part-time job. The provider makes sure that he receives support to make his dinner upon his return from work.
Supporting people in decision-making about their employment
Justin was not sure whether he would like to work in the community because he had previously only participated in center-based work. His employment provider coordinated opportunities for Justin to visit some community job sites and businesses that were of interest to him. That way, he had some real-life experiences on which he based his decision.
Providers may help people make informed choices about whether or not to pursue employment by:
Using person-centered practices to discuss the opportunity to work with people regularly
Discussing the positive outcomes of employment, including meeting people, learning skills and making money
Helping people to learn about how work will affect their benefits. Resources for people include case workers, Disability Hub MN and Minnesota Department of Employment and Economic Development (DEED) counselors.
Supporting people whether they want to seek work or not.
If people decide they want to work, they may make informed choices about their next steps by examining their strengths and interests to help identify potential jobs, researching work opportunities and networking to get assistance and learn about job prospects. People may also get help exploring work from family, case managers and providers.
If people decide not to seek employment, providers should routinely review with them their right to work. This practice of periodically returning to the topic allows providers to keep up with changes in people’s needs or preferences.
Promising practices from HCBS providers
Using person-centered practices to understand people’s goals and desires related to employment
A staff member works with each person to review an employment interests and goals form that asks specific questions about preferences for person-centered employment. Each person revisits this form with a staff person regularly. We have also begun to customize the forms in specific ways for different types of work. For example, several people have started making and selling art or working as performing artists. In this case, we added an additional page to the form to explore specifics about selling art: Artists are asked about their interests and how their art can best be sold in the community.
There are many benefits for people who work in their communities, including:
Feeling more connected to the greater community. People who work report having a higher number of friendships and connections to people without disabilities through work.
Believing more in their abilities. Working allows people to challenge themselves and reach their maximum potential. They have higher expectations of what they can accomplish, and this feeling spreads to other areas of life outside of work.
Having better health and sense of well-being. Working allows for people to be active, and people report feeling better about themselves because of it.
Having meaning in their lives. Having a job allows for people to be engaged with their communities. People feel engaged in meaningful activities that help those around them.
Making money. People with developmental disabilities make significantly less money than workers without developmental disabilities. They often live in or near poverty, but having a paying job helps supplement resources and improve their quality of life.
Promising practices from HCBS providers
Building community relationships through employment
Six people we support have worked for several years at a routine paid job cleaning bathrooms and mopping floors at a neighborhood bar. They have developed natural relationships with the staff at the bar, who are polite and engaging. The bartender serves them free soda or juice after they are done cleaning, and they sit and visit at the end of their shift.
With careful planning, people who need benefits may choose to work while remaining on a public health coverage program and maintaining their disability assistance. Many myths about work costing people their benefits are false.
The Disability Benefits 101 website is a resource that provides information to help people understand the impact of work on their benefits, including:
An explanation of Ticket to Work, a voluntary federal program that is intended to help adults with disabilities who get Social Security disability benefits earn a higher income and become more self-sufficient. The program helps people to get training, job placement and coaching, and vocational assessments. The program helps people to become more independent and reduce their need for Social Security benefits.
Details about how working affects Supplemental Security Income, which might go down as people work even as people’s overall financial situations improve through a combination of SSI and their pay
Information about how a job affects Social Security Disability Insurance, which allows for a 9-month test period in which people may evaluate if joining the workforce is the right move. People may receive full benefits while earning any amount of income during the trial period. Income restrictions do apply after the trial phase.
A description of how people may keep their health coverage while employed. The options range from getting coverage through an employer to programs that help people stay on Medicaid while they work.
People can understand how work will affect their benefits by contacting their financial worker or connecting with:
A DEED counselor, who can provide full information about how work will affect people’s benefits and how to keep medical benefits while working
Disability Hub MN, a free resource network to help people solve problems, navigate the system and plan for their future
The Senior LinkAge Line, a statewide assistance and information service.
Promising practices from HCBS providers
Exploring potential effects of wages on benefits
A staff member helps Anastasia to explore her skills and interests to help her identify potential job opportunities in the community. Then, they research the wages and benefits for those opportunities and conduct a benefit analysis to see how her wages would affect her public benefits. Through this process, she can make an informed decision about employment.
On July 1, 2018, Minnesota added three employment services to its HCBS waivers: employment exploration services, employment development services and employment support services. These services are available with the Developmental Disabilities (DD), Community Alternative Care (CAC), Community Access for Disability Inclusion (CADI) and Brain Injury (BI) waivers. The three employment services have unique purposes:
Employment exploration services: Community-based services work to introduce people with disabilities to employment opportunities in the community. This allows people with disabilities to explore career interests and experiences and make an informed choice about working in an integrated setting.
Employment development services: These services are individualized and help people find employment, whether it be in a competitive and integrated setting, self-employment or creating a microenterprise in their community.
Employment support services: These services are individualized to help people maintain employment in the community. The services may help with transportation, job training, coaching to strengthen work skills and various forms of advocacy with an employer.
No. DHS designed the employment services to help providers to better support competitive, integrated employment. They are about adding options, not taking them away. Center-based services and subminimum wages will remain an option. Work crews will, however, have a maximum staffing ratio of 1:6.
Disability Benefits 101 is a website that helps people with disabilities to learn how income might affect benefits and provides support for going to work.
DirectCourse’s 4.3-hour Supporting Jobs and Careers in the Community class offers four lessons: Successful Community Employment and Retention; Employment Supports and Volunteering; Introduction to Government Benefit Programs; and Government Benefit Programs and their Interaction with Work. The College of Direct Support courses are written for support staff who work with people with disabilities; however, the content can also be adapted for working with older adults.
DirectCourse’s College of Employment Services offers several courses relevant to HCBS settings, including Foundations of Employment Services and Strategies for Job Development.
The DHS Employment First webpage offers information on Minnesota’s Employment First efforts, employment services, training, resources and success stories.
The DEED website offers information, resources and services on employment. It has a section specific to job seekers with disabilities.
The Disability Hub MN website offers information, resources and services for people with disabilities and those who support them and has a section specific to employment.
The Senior LinkAge Line can connect people who want to volunteer to resources and organizations.
The MinnesotaHelp.Info website provides information about volunteering. To find resources, search “volunteer opportunities” or “retired and senior volunteer program.”
This orientation manual for direct support professionals and supervisors (PDF) from the Virginia Division of Developmental Services helps you to think about and interact with people with disabilities in the same way you do with people who do not have disabilities. This resource is written for people with disabilities; however, the content can be applied to older adults, as well. Specifically, pages 16-17 address employment.
