Service name and California service codes as per rate model

Supported Living Service (896)

Conceptual Definition of Supported Living Services

Supported Living Services (SLS) are provided to adults with intellectual and/or developmental disabilities who are living in a home that they own, rent or lease, with control over both their living situation and who provides their support.

Supported living services provide people:

• With as much support as they need, for as long as they need it,

o to have meaningful choice and control in all aspects of their lives,

o to establish and maintain a safe, healthy, stable and independent life,

o at home and in the community.

• With services and support that change as needs, preferences and goals change.

Models/options available under regulations or in the Home and Community Based Services waivers in California

Individual Supported Living – staff provide support to individual(s) living together in one setting (behind one front door). Can be up to 24 hours.

Shared Supported Living or Supported Living Community 1 – support is provided on an up to 24-hour basis – staff provide support to one or more individuals across multiple units (several front doors e.g. in the same block of apartments).

Parent Coordinated Supported Living (073) is a different service code, but all the elements and definitions would be the same. The key difference is that staffing is organized by a parent. The parent takes on the role and responsibilities of the employer and it requires the use of a Financial Management System.

1 In the California Rates Study (Burns et al., 2019) this is included under residential services (page 71). Individual support living is included under Personal Supports (page 61).

Eligibility and limitations in California

Who is eligible?

• Adults with developmental disabilities (age 18 and over)

Living situation

• SLS is provided in a home (as defined by Code Regs. Tit. 17, § 58601) the person owns, leases or for which the individual has a rental agreement. Living arrangements must be typical of those in which people without disabilities live.
• SLS cannot be provided in the home in which the conservator or parent resides.
• People may not receive services in a home in which the SLS agency “has any financial or fiduciary involvement unless the individual and the regional center director give consent”. The agency providing SLS services does not own the home, act as landlord, or have its name on the lease agreement.

Intensity and duration of support

• Supported Living services can be provided as often and for as long as needed, with no limitations on frequency of support. Lanterman Act: “Consumers shall not be excluded from supported living arrangements based solely on the nature and severity of their disabilities”.
• The amount of support is determined by an assessment of the person’s needs as part of the IPP process and can be for up to 24 hours a day (in person or remote/on call). Based on level of need, people may have more than one staff member providing support. Support can vary over time depending on an individual’s level of need or current situation.

Cost-containment regulation introduced in 2009 stated that:

• Generic services and natural supports must be maximized before supported living services can be funded.
• Utilizing the same supported living provider for people living in the same house is encouraged, providing that the particular needs of each individual can still be met according to their Individual Program plan. Having more than one provider working with individuals living together is only permitted if it has been determined by the IDT that the current provider is unable to meet the needs of one of the individuals.
• Individuals receiving services must choose the most cost-effective provider/vendor if more than one provider/vendor is available to meet their needs.
• Shared Supported Living became an option – however, housing arrangements provided under this model should still meet the definition of community living - an “ordinary house in an ordinary street” – here “ordinary” means a house that is chosen from among the same range of housing options used by people without disabilities.
• Individuals living in a house must pay their fair share of the rent, mortgage or lease payment – this includes the people receiving services, housemates and live-in staff. Regional Centers will only supplement a service recipient’s rent, mortgage or lease payment:

o Via an exception process,

o On a time-limited basis

And,

o When all available sources of natural and generic supports have been utilized to the fullest extent possible, with evidence of this provided by the individual’s planning team.

Type of support provided

A supported living service can provide support for every type of activities or needs that relate to establishing and maintaining a “safe, healthy, stable and independent life” with choice and control over their living arrangements, support and daily routines. Supported living can include anything that the person requires to meet their unique needs as set out in their individual program plan, including but not limited to medical and health care services (excluding physician services), personal care, behavioral support, advocacy, emergency preparedness and emergency relief for personal care attendants.

Supported Living Services cannot be used to provide support in employment (although can be used to support an individual to identify and work towards employment related goals and access community resources and facilities that will support the development of skills related to work).

Supported Living frequently involves providing support to participate in, maintain existing skills in and develop new skills related to:

• activities of daily living (such as personal care and hygiene, planning, preparing and eating meals, maintaining their home)
• community life and building relationships, including building a Circle of Support
• locating and scheduling medical services,
• managing their finances,
• finding, selecting, modifying and moving into a home,
• locating and selecting those they wish to live with,
• acquiring furnishings
• recruiting, training and hiring their direct support professionals,
• managing their staff (including directing and firing)
• acquiring, using and caring for or maintaining assistive technology or support animals.
• developing goals, including related to employment.
• self-advocacy

Supported Living Services providers are obligated to develop plans to meet the critical needs of individuals in circumstances such as:

• Disaster (fire, earthquake, flood)
• Public Health Emergency (flu, or other communicable disease)
• Infestations (bedbugs, roaches, rodents, etc.
• Disruption of essential utilities and services (power failure, water contamination, etc.)
• Civil unrest or disobedience (riot, strike or uprising).

Funding source in California

Regional Center (once generic services such as In Home Supportive Services (IHSS) and natural supports have been maximized).

How to access Supported Living Services

Supported Living services are requested by an individual or a chosen/legal representative.

• The Individual or their chosen representative expresses a desire to their Circle of Support/IPP team (Individual Program Plan) that they would like to access supported living services.
• An IPP meeting is scheduled.
• Once it is agreed that the IPP will include Supported Living Services, a Purchase of Service (POS) is issued.
• The person and/or their chosen representative will be asked to choose a provider, with help if needed.

• A comprehensive assessment will be carried out so the provider can get to know the person’s needs, desires, etc. This will be used to draft the Individual Service Plan (ISP).

• Once the draft ISP is agreed (usually at another IPP meeting) the SLS provider will help the person to find a home,

Other terms/names associated with this service type

No other terms used.

Falls under “Habilitation - Residential or Home-based” in the CMS (Centers for Medicare & Medicaid Services) Taxonomy and HCBS Waiver guidance.

Vendor requirements

Vendor requirements (including required staff training and qualifications) are set out in: California Code of Regulations. Title 17, Chapter 3, subchapter 2 – vendorization and in Chapter 3 subchapter 19 Supported Living Service.

Key characteristic/Principle

4

Description of principle/characteristic

Expectations and evidence that a service is providing supported living – what should you see?

A home of one’s own

• Individual lives in a home that they own, lease or rent like other members of their community
• Individual chooses where and with whom they live
• Individual controls what happens in their home
• Housing is separate from support and they are secure in their home
• Individual is safe in their home and neighborhood

What the individual receiving the service would experience

• The individual is living in an ordinary house in an ordinary street (chosen from among the same range of housing options as used by people without disabilities).
• The location of the home makes it easy for the individual to access the facilities and activities available in the local community.
• The individual’s name is on the mortgage, lease or rental agreement and

o The individual can remain in their home even if their needs, services or service agency changes.

o The individual can move to a new house and not lose supported living services. The services and support the individual receives is NOT tied to the home they live in.

• The individual expresses, or there is documentation that shows, that they chose where they live OR that they have made an informed decision to remain in their current home when the possibility to move arose.
• The person has a “key” to their home and is supported, if needed, to use it.
• Other individuals have a key only if the individual chooses to give them one. In other words, the provider agency does not have a key and the support staff are not automatically given a key.
• The individual is fulfilling the responsibilities of having their own home - paying bills, looking after the home, deciding how to decorate it – with as much support as they need to do so successfully
• The individual is answering the door and telephone
• If sharing with others, the person has a space they can call their own and enjoy privacy and the ability to lock doors.
• Individual has choice and control over the home routines – when things are done, how things are done, where things are stored, when family and friends can visit, etc. 
• The individual can move around and access all areas and activities in their home easily – it is accessible and adapted to their needs.

  The individual expresses that they are, or show in their behavior that they feel, comfortable and safe in their home and neighborhood.

Other evidence/indicators

• Staff and visitors treat the place as the person’s home - ringing the bell, knocking doors, asking permission to use the bathroom, make a drink for themselves, etc; they respect people’s property and use language that indicates they understand this is the individual’s home.
• No signs or other artefacts that identify the home in any way as a “service”.
• The person’s rights of privacy, dignity, respect and freedom from harm and coercion are respected. Incidents of harm, abuse or neglect that occur are reported as per Mandated Reporter Requirements (Welfare and Institutions Code Section 15600) and Special Incident Reporting (SIR) requirements (Section 54327 of Title 17 of the California Code of Regulations).
• Vendors of Supported Living Services would not have a financial interest in the housing nor would they act as a trustee for the housing arrangement.

2 https://www.medicaid.gov/sites/default/files/2019-12/requirements-for-home-and-community-settings.pdf 

3 https://publications.ici.umn.edu/rtcom/briefs/brief-three-development-of-hcbs-outcome-measures

4 Principles and descriptions drawn from Bolton and Allen (2000) Guidance for providers on developing supported living: https://www.dds.ca.gov/wp-content/uploads/2019/02/DevelopingSupportedLivingServices-1.pdf  

Choice and self-directed

• Individual makes their own everyday choices. Individuals plan for their futures.
• Individual directs the services they receive and has a choice of agencies and staff. Individual is supported (e.g., technology, communication devices, behavioral support) to 

  communicate their preferences, choices and needs.

• Individual is satisfied with the services they receive.

What the individual receiving the service would experience

• The individual would be trying new things, going new places, meeting new people (at a pace that works for them). Without this people do not have the experience they need to make choices and develop future goals.
• The individual would be making a range of day-to-day choices every day – how to spend their time, what to eat and drink, etc. in a way that is adapted to their needs/manageable for them.
• The individual would be in control about how things happen – e.g. in what order, when, where, with whom – in all areas of their lives, in a way that meets their needs and preferences
• The individual would be involved in decisions about the bigger things in life – where to live, work, where to go on holidays, how to spend their money, which agency and staff to employ, the type of support and when it is provided. 
• The individual is involved in recruiting new staff and is supported to manage their staff where possible.
• The individual would have a dynamic and regularly updated person-centered profile to share their needs, preferences etc with those who support them to reduce the need for “guess work” as much as possible, when and if needed.
• People would have a Circle of Support (ideally independently facilitated or at least with an independent advocate present) who can support them in making informed decisions.
• People would be directly involved in the development of their person-centered plan and in meetings about them, as much as they wish to be.
• If people are not able to express wishes, desires, dreams etc in meetings, we would see their circle of support discussing and taking into account the person’s preferences, previous experiences, wishes etc.

Other evidence/indicators

• Staff would be using the type of communication that works for the individual and the person would have a reliable and accessible way to make choices, express preferences etc.

• Those providing support would be respecting the choices and decisions made by the individual and carefully balancing choice and control, rights and responsibilities and duty of care. They would not be imposing their own values or ways of doing things on the people they support.

• There would be no seclusion or restraint or physical behavioral interventions.

Relationships

• The individual has family, friends and neighbors who support them in regular ways or as paid help.
• The individual and their circle of support work together as a team with the supported living agency and others to share responsibility for their well-being.

What the individual receiving the service would experience

• The individual would have regular contact (as regular as they appear to want and is physically possible for them to have) with family and friends. Family and friends can visit whenever the person would like them to visit.
• The individual would have a range of different types of contacts – different people playing different roles
• Their relationships would be respectful, positive, helpful, supportive and compassionate, a source of fun and enjoyment (at least most of the time)
• Individuals would have friends who are not paid staff and who would engage in shared interests with them.

• Individuals would be greeting their neighbors and vice versa; being known by name; helping out neighbors or giving gifts; joining in neighborhood events; sharing meals etc.

Other evidence/indicators

• Services would be providing opportunities to people to meet and interact with others who are not paid staff and who have similar interests.

Community Membership

• The individual fully participates in the mainstream of community life according to personal choice and preference.
• Individual has opportunities to join clubs, groups, organizations, and religious groups.
• Individual uses local community resources and generic services.

What the individual receiving the service would experience

• The individual would be accessing regular community life in a way that works for them – working in integrated settings, participating in the same clubs, groups, churches, public services and transport, shops, leisure facilities, work environments, as other people without disabilities.
• People might also be contributing on a grander scale – working and paying tax; sitting on advisory boards or stakeholder groups; standing in local elections etc.

Other evidence/indicators

• We would see or hear about individuals being recognized in these settings, referred to by name and over time have a sense of belonging.
• We would see or hear about individuals contributing to their community – volunteering, helping at charity events, taking up collection in church, picking up litter….

Flexible, Tailored Services and Supports

• Individual Service Plans are developed through a person-centered planning process.
• Service plans reflect the support that each individual wants and needs and plans change as the individual wants and needs change.
• Individuals have opportunities to increase their abilities, confidence and quality of life and support to maintain an adequate level of health and safety.

What the individual receiving the service would experience

• People have a detailed person-centered plan or at least a comprehensive person-centered profile documenting what is important to and for the person.
• Individuals are trying new things - having new experiences, learning new skills, acquiring new knowledge and succeeding – this is what we all need to increase our competence, confidence and self-esteem and emotional well-being.
• People and families would report that support is provided when and how they need it.

Other evidence/indicators

• Goals reflect what is important to the person, not just for.

• Those providing support would be aware of the person’s needs, preferences and skills and would be using the right communication methods and the right level and type of support for each individual.
• Those providing support would be adjusting their support to match where and how the person is today – e.g. taking account of physical and emotional well-being.
• Services revolve around and are moulded to the individual rather than the individual being “squashed” into whatever shaped box is available.
• No “blanket assumptions” or “diagnostic overshadowing” – support would be truly individualized.