Active vs. Passive Support

Introduction

Recently, there’s been a lot of conversation about what exactly “Active“ and “Passive“ mean in the context of Remote Supports. Here, we’ll outline the issues with current conceptions of “Active“ vs “Passive“ discussions, pull apart the two terms, establish their respective definitions, and recontextualize the conversation.

Background

Originally, terms like “Active“ and “Passive“ Remote Supports were marketing terms designed to help explain certain aspects of the service. Because the service was new at the time, Remote Support providers had to come up with plain language that communicated the different service capacities of Remote Supports.

For example, an RS provider might refer to a check-in as an “active“ component of their support because it is initiated by the RSP and involves direct, two-way communication between the Remote Support Professional (RSP) and the individual. Conversely, they might describe the way that RSPs survey sensor data in real time as “passive“, because it doesn’t involve direct, two-way communication and happens “behind the scenes.“

Additionally, RS providers used these terms to differentiate their specific brand of services from other RS providers. For example, a provider that uses cameras as a common part of their services might say their specific brand of Remote Supports is, generally speaking, more “active“ than ones that don’t use cameras.

Problems with “Active“ vs “Passive“

Problems with the terms “active“ and “passive“ arise when they are taken out of the context of general education and marketing and are instead used as regulatory terms. Because “active” and “passive“ have different meanings even among different RS providers, establishing regulatory requirements based on these terms causes confusion and compliance headaches.

Defining “Active” and “Passive“ Remote Supports

When attempting to lay out a concrete definition for these two terms, it’s important to understand that there are not two separate and distinct services, “Active” and “Passive“ Remote Supports. Rather, all Remote Supports have active and passive elements within them, depending on the individual’s specific needs and Remote Supports Plan.

Active Supports

Active elements can be thought of as intervals of direct communication with the individual. This could be a two-way audio or video call. The cause for these short stretches of direct communication, or “active support“, could be something like the activation of a sensor (e.g. John presses his pendant to get in touch with an RSP), a scheduled intervention (e.g. Jane gets a call every day at 6a to remind her to pack her lunch for work), or a combination of the two (e.g. Billy gets a call in the afternoons to check on how he’s doing whenever his Front Door sensor indicates he’s arrived back from Day Program).

Regardless of the cause, these stretches of direct communication have specific characteristics: First, they’re brief. When compared to consecutive hours of in-person staff presence during a residential habilitative service, these periods of direct communication during Remote Supports are short. Some can be as quick as a minute, some can last as long as fifteen minutes, but overall they are relatively short.

Second, they address a specific need/goal/intended outcome. Check-ins are performed to see if the individual is present, safe, and happy. Reminders are intended to help individuals remember certain things needed to live independently. Responses, such as John’s example above, are often just to reassure the individual that someone is supporting them and answer questions that they may have in the moment.

Passive Supports

Passive elements of Remote Supports comprise all the times that these intervals of direct communication are not occurring during the scheduled Remote Supports period. For example, if an individual has overnight Remote Supports from 10p to 6a and has a reminder at 5:30a, then the periods from 10p-5:30a and 5:35a-6a are all considered passive.

This may seem like a lot of passive time, but let’s remember why Remote Supports are implemented in the first place. The goal of Remote Supports is to provide a safe environment where individuals can exercise and develop skills related to independent living. The purpose is to create an environment where they can reach out to someone immediately if they have a problem, question, or concern, but also where certain elements of behavior that may complicate independent living (e.g. a tendency to let strangers in the home) can be mitigated.

During times of passive support, RSPs are still actively engaged with the individual’s Remote Supports system, they just aren’t in direct communication with the individuals themselves. If we take the example above of an individual who struggles with visitor safety, we can imagine a DSP who works in the home to help with that specific concern. During an overnight period of support, the DSP may not be engaged in direct communication with the individual, they’re just keeping an eye and ear out for the doorbell or people entering the home. We can imagine the exact same absence of direct communication in that period with an RSP. Except instead of using their eyes and ears to listen to the door that’s right next to them, they’re using the information from door sensors to monitor whether it opens during the night. Both examples are instances of “passive“ support. They are awaiting a set of circumstances that would require them to intervene.

Conclusion

It may seem that more “Active“ support would be preferable for most folks. More direct communication = more support = a better outcome for the person served, the thinking goes. This isn’t the case. Like most in-person residential services, Remote Supports are intended to be habilitative. Though the method of habilitation differs from services with in-person DSPs, the intended outcome is the same: to help bring individuals to a place where they can live with fewer and fewer supports while remaining safe and successful. For individuals using Remote Supports, this means that the goal is to end up with supports that are as passive as possible.

CAIRSS Remote Supports Integration White Paper

Best Practices for Remote Supports Integration into State HCBS Waivers

Ben Richter, Director of Development, Night Owl Support Systems, LLC - Member of CAIRSS

Abstract

The persistence of the national staffing crisis in long-term care services, particularly residential services for people with intellectual and developmental disabilities, necessitates the integration of alternative service models. Remote Supports, a service in which technology connects an individual to a caregiver at a remote location, is one such alternative. It has been implemented into HCBS waivers in many states, where it has demonstrated a capacity to reduce the negative impact of staffing crisis and generate savings for Medicaid. However, the implementations among different states have not been equal. States that preserve the financial incentive for providers to use Remote Supports, establish robust requirements for Remote Supports operation, and allow individuals to utilize as many units of the service as they desire to reach their intended outcomes set an example of how such implementations should be accomplished. We urge CMS to issue federal guidance to promote state establishment of Remote Supports services in their HCBS waivers and to promulgate the benefits of other states’ successful integration efforts to help them move toward integration that removes the most barriers toward utilization and provides the most benefit to the most people.

Background

The long-term care services industry has been enduring a protracted staffing crisis for several years. High turnover of Direct Support Professionals (DSPs) results in higher costs for organizations (National Core Indicators, 2022; Larson, et al., 2016). The consequences of this crisis have several downstream effects, including discontinuation of programs and services as well as leaving providers struggling to achieve quality standards (ANCOR, 2022). The persistent nature of the staffing crisis, despite federal relief from sources such as the American Rescue Plan Act, demonstrates that infusions of funds are not sufficient to solve it. There is a need to fundamentally reconsider the structure of residential services to integrate Remote Supports in ways that will help reduce aggregate reliance on in-person staff.

State HCBS administering departments and providers have come together in many states to develop and implement technology-based services and solutions to help reduce reliance on in-person staff and increase participants’ independence and community-integration. Ohio, Missouri, Minnesota, and Maryland are just a few of the states to have adopted a “Technology First” framework for addressing the needs of HCBS participants (Wagner, Tasse, Ornan, 2022).

Functionally, efforts such as “Technology First” initiatives seek to prioritize the implementation of supportive technology services and solutions available to HCBS participants to achieve the positive outcomes discussed earlier. Examples of these services and solutions include Remote Supports, assistive technology, environmental controls, and supportive applications.

The onset of COVID-19 and the flexibilities allowed through Appendix K created the exigencies which prompted many providers of residential HCBS services to explore technology-based solutions to their persistent staffing problem. With the rollback of these flexibilities, many states and providers are left deciding how to navigate their way out of the public health emergency without relinquishing many of the innovative service models they have developed (Tanis, 2021).

Fortunately, there are services that utilize technology to reduce reliance on staff and improve the outcomes of the people supported. One service, the focus of this paper, is Remote Supports. Remote Supports are uniquely positioned to create the broadest possible benefit for states, individuals, and providers, if the method by which they are integrated into HCBS waivers is correct. In the following text, we will examine Remote Supports, benefits of the service as a whole, the different permutations of definitions as they currently exist in HCBS waivers, and how those definitions support or hinder the potential benefits of the service for all stakeholders.

Remote Supports Defined

According to the Coalition for the Advancement and Integration of Remote Supports Services, the following is the definition for Remote Supports services:

“Remote Supports is a technology-based service that allows trained Remote Support Professionals (RSPs) to deliver live support to an individual at a remote location. Its primary goal is to foster an individual’s safety and to allow them to live more independently. Remote Supports are delivered by awake, alert Remote Support professionals whose primary duties are to provide Remote Supports from the provider’s secure Remote Supports facility. To ensure safety and HIPAA compliance, this facility should have appropriate, stable, and redundant connections. This should include, but is not limited to backup generators, multiple internet service connections, battery backups, etc. Remote Supports should always be selected as the result of decisions made by the individual and their team. Remote Supports must be incorporated into the individual’s personalized service plan and must be executed in a person-centered fashion.” (CAIRSS, 2021).

While CAIRSS and its constituent members consider this the primary definition of Remote Supports, many states have definitions within their HCBS waivers that vary to greater and lesser degrees. Indeed, many states functionally provide Remote Supports under other names, or combine Remote Supports provisions with residential service definitions (as a virtual service option) or with assistive technology.

Remote Supports Compared to Other Technology Solutions

Remote Supports differ from Assistive Technology, Environmental Modifications, Personal Emergency Response Systems (PERS), and other related HCBS services in fundamental ways. First, and perhaps most importantly, Remote Supports is a service (not to be confused with the HCBS Participant Services, under which all HCBS offerings are defined). Remote Supports occur over time and are not related to the distribution of discrete pieces of technology, but rather how specific technology systems allow for the person-to-person support of an RSP to an individual-served.

Assistive technology, as traditionally defined by the 1988 “Tech Acts” and subsequent reauthorizations in 1994, 1998, and 2004, refers to discrete devices that improve the functional capabilities of people with disabilities. There is a one-to-one correlation between the device provided and the outcome supported. Similarly, Environmental Modifications, Vehicle Modifications, and Accessibility Adaptations refer to discrete integrations of specific technologies intended to address a specific set of outcomes. Remote Supports are a service intended to address several outcomes, accomplished through technology, whereas Assistive Technology are devices that are purchased and intended to address specific outcomes.

Remote Supports are also related to PERS, insofar as they both function as a system that provides a service. They both establish a mechanism by which individuals can contact a staffed call center in case of emergency. However, they still differ in three substantial ways.

Firstly, the call center associated with PERS devices is almost always staffed with representatives who know nothing about the individual other than very basic demographic information such as name and address. They only retain the information needed to dispatch emergency services. Remote Supports, on the other hand, have similar remote locations from which communications are established, but are staffed by trained RSPs who are more akin to DSPs than EMS dispatchers. These RSPs are trained on a set of protocols, which act as a plan of care for Remote Supports services, that include more information than basic demographics. What’s more, their training includes many of the HCBS-specific subjects, including HIPAA, Preventing Abuse, Neglect, and Exploitation, Rights of Persons with Disabilities, etc., that DSPs are required to undertake.

Secondly, Remote Supports are not simply a standby service that is rarely engaged, like PERS. Instead, they are an active part of an individual’s daily life. Examples of discrete activities performed by RSPs include: providing prompts, redirecting individuals, giving reminders, and responding to non-emergency communications initiated by the individual.

Thirdly, Remote Supports function as a replacement for some hours of residential staffing services. It is commonplace in the industry that individuals often have staff in their homes during “downtime” or periods of inactivity where the individual’s needs are low, but not so low that the staff person can leave them alone in their home. An example of common downtime is during overnight periods. Remote Supports flourished through much of its twenty-year history by replacing overnight staffing hours. These periods have low-activity, and when help is needed, responders or backup staff can be dispatched to aid them.

Core Components of Remote Supports

Remote Supports are comprised of four core components: the individual served, the Remote Support Professional, the technology used to connect them, and the backup/response staff. Understanding these core components proves essential to grasping the effects of regulatory decisions on service delivery and the potential for benefits of the service (to be outlined in the following section) to be diminished through inadvertent regulatory action.

During the provision of Remote Supports, an individual served is at their home (or in the community, but for the purposes of this prototypical example, we will focus on the residential situation) and the RSP is working from a central station. Through technology, including sensors and two-way audio/video communication, the RSP is supporting the individual as they accomplish their Activities of Daily Living. Should the individual require in-person assistance, the fourth component, backup response, can be dispatched to the home in a timely manner. This arrangement proves efficient, as it at once allows the individual to have more time physically alone in their home while still preserving the capacity for rapid response if in-person help is required.

Each of these components is essential for the provision of safe and effective Remote Supports. Without the technology, the RSP and individual are unable to communicate, which presents safety concerns. This is why regulations regarding technical backups, including redundant connections and backup generators, are important. Without backup responders, Remote Supports would be unable to appropriately account for unforeseen circumstances that require in-person care, presenting safety concerns.

The necessity of these components, in addition to the responsibility for adequately regulating them, supports the creation of a separate definition for the service. Funding or otherwise authorizing the service through current service models such as AT and PERS does not provide the regulatory flexibility necessary to ensure the safe operation of Remote Supports.

As will be demonstrated later, the varying methods by which states implement Remote Supports, including, in many cases, by placing them within AT and PERS services, has impacts on the relative benefits of the service for the individuals using HCBS waiver services. Such marked differences support the creation of a Remote Supports definition at the federal level, one which all states can reference when updating or creating their Remote Supports service models and which will preserve the core components that have proven safe and effective.

Benefits of Remote Supports

With the understanding that benefits of Remote Supports are subject to the regulatory context in which they are offered, let us turn now to the benefits of Remote Supports when adequately provided for in HCBS waivers.

First and foremost is the benefit to the individuals who receive these services. For many people with intellectual and/or developmental disabilities who receive residential services through HCBS waivers, in-home staff are often present for times when active, hands-on support is not necessary. This “down time” can be a result of administrative determinations of the level of supervision (for example, if individuals are deemed as requiring twenty-four hours of care) or the result of simple pragmatism (for example, if the individual needed lunch prepared for them, but will also need help preparing for work two hours later, it doesn’t make sense for a DSP to leave and then return for the other period of help). Regardless of the cause, these periods of “down time” are essentially times where an individual could otherwise be alone and independent in their home, if certain mechanisms were put in place. Remote Supports affords such a mechanism.

With Remote Supports services, individuals who would otherwise have staff physically present can be alone and independent in their home, while preserving their safety. Indeed, the Nisonger Center at the Ohio State University conducted a study that reported the number one benefit, according to individuals receiving Remote Supports services, was safety. The second most reported benefit among individual participants of Remote Support services was independence (Tasse, Wagner, et al. 2020). While more research is necessary to determine the extent to which this service promotes increased independence among participants, among those who use the service the benefits are real.

To better illustrate these benefits, take for example the hypothetical Mr. B. Mr. B receives waiver services in Indiana, where he lives alone in his own apartment. Before Remote Supports, Mr. B received Residential Habilitation services, where a DSP would come to his apartment and help him with Activities of Daily Living. However, Mr. B made it clear during team meetings that he wanted more independence and responsibility for those ADLs. Mr. B struggled with remembering to perform basic tasks and how to accomplish them even if he remembered what he was supposed to do. To help support him, Mr. B and his team decided to use Remote Supports. With this service, Mr. B was able to exchange hours of DSP support for hours of Remote Support, during which he took charge of his ADLs. When he struggled or needed help, he would reach out to his RSP for guidance, who would either help resolve the issue or dispatch a DSP backup/responder to his home.

As CMS pushes for compliance with the HCBS Final Settings rule and promotes the adoption and implementation of person-centered practices that promote individual choice and self-determination, it appears that Remote Supports, when included in the array of potential services, is poised to help achieve those ends.

ends.

Aside from the primary benefits of increased independence to individual HCBS participants, there are also benefits for other stakeholders. Residential service providers also see benefits from integration of Remote Supports services into the care matrices of the people they serve. When more DSPs are taken away from situations with “down time” and applied as backup responders to individuals receiving Remote Supports, labor efficiency increases. Instead of idle time, DSPs can be deployed where they are truly needed for all hours with some being leveraged for those backup responder roles. Even individuals who are not suitable or do not wish to use Remote Supports can benefit from these increased efficiencies. If a DSP is no longer required to be present at the home of another individual who is utilizing Remote Supports, then they are freer to address the needs of those other individuals not using the service.

Consequently, there is significant potential for organizational-level implementation of Remote Supports services to reduce the costs associated with the high turnover of DSPs. Overtime, HR, and training expenses are a few examples of such costs that could diminish with staffing stabilization achieved in combination with expanded Remote Supports utilization (Larson, et al., 2016).

Both the direct and indirect labor benefits of Remote Supports integration have immense potential to positively impact residential providers who are suffering from the staffing crisis. It has been reported that 86 % percent of providers believe that greater applications of technology can help address the national direct support professional workforce crisis (Tanis, 2021). Effective implementation of Remote Support services across the states’ HCBS waivers has the potential to dramatically reduce reliance on in-person staff and provide a lifeline to providers struggling to meet the needs of the people they serve.

But the benefits of Remote Supports services are not limited to increased independence for individuals and labor-efficiency for residential service providers. Because of the inherent efficiencies of Remote Supports services, they can be provided more cost-effectively than in-person residential services as well. One RSP may be supporting several individuals simultaneously, thus the cost of one hour of labor is spread across many different individuals’ waivers, as opposed to situations with DSPs, where the cost of the DSP’s labor comes from the single individual’s waiver alone. The results of this cost-effectiveness means that individuals can receive a service that promotes their independence while at the same time residential providers (so long as they are allowed to capture some portion of the savings) and the state pay less per unit of service delivered.

With benefits to the individual’s served, residential providers, and states, Remote Supports is poised to become an integral part of the solution to the protracted staffing crisis facing the nation. Given the potential benefits, it is incumbent on the CMS to promote the integration of the service into the waivers of all state/provincial HCBS waivers.

How States Offer Remote Supports

The former sections have laid out the “what” and the “why” of Remote Supports. In this section we will examine the “how,” diving into the differences between different state’s efforts to implement Remote Supports services and how those respective efforts affect each state’s capacity to enjoy the benefits of the service listed above.

At least thirty states allow for Remote Supports services in some capacity. However, the service is underutilized or poorly regulated in most of these states. This section will not attempt to cover the differences among all these states. Instead, it will highlight some major differences and their respective implications. The goal is to delineate a method for adding Remote Supports services to HCBS waiver offerings in a way that benefits the most waiver participants and other stakeholders.

Indiana and Ohio: Two States with Successful Remote Supports Integrations

To benchmark effective Remote Supports integration and have a foil against which we can evaluate other attempts to integrate, we will start with an examination of the regulations of Indiana and Ohio, both of which have successfully added Remote Supports to their HCBS waivers. Indiana allows for Remote Supports in a few different ways. There is a per se service in their two waivers, Community Integration and Habilitation (CIH) and Family Supports Waivers (FSW), but the state also allows for Remote Supports to be provided on a subcontracted basis as part of residential services (Residential Habilitation and Supported Living). This arrangement allows ResHab providers to subcontract with Remote Supports providers to provide some hours of Remote Supports during downtime periods where in-person staff would otherwise be required.

There are many benefits to this method of integration, whereby subcontracting and state contracting are both allowed. Firstly, the flexibility acknowledges the inherently close nature of Remote Supports to traditional residential staffing services. Indeed, a provision of Indiana’s regulations regarding Remote Supports requires that backup staff/responders be outlined in the individual’s Person-Centered Individualized Support Plan (PCISP). The subcontracting arrangement allows for staff from an individual’s regular residential provider to be that backup staff/responder during the hours Remote Supports is being provided. Residential providers need only pay the Remote Supports provider their fee for Remote Supports services out of the typical residential daily rate they are reimbursed for from the state.

Secondly, Indiana and Ohio’s methods for allowing Remote Supports provide a financial incentive for providers to adopt the service. Take a hypothetical provider in Indiana for example. For every hour of downtime, they switch from in-person staffing to Remote Supports, they are able to not pay a staff person but instead pay the Remote Support provider’s fee. Because of the inherent efficiencies of Remote Supports providers, they can provide the service at a rate consistently lower than that of in-person staff. As such, residential providers in Indiana make more money when they switch downtime hours from in-person staffing to Remote Supports. This financial incentive has proven a key aspect of successful Remote Supports integrations into HCBS waivers, and the absence of such a financial incentive has likewise generated tepid responses from providers.

Thirdly, Indiana and Ohio both separate out their Remote Supports services from other technology-based services, such as Assistive Technology and Environmental Modifications. This separation has two positive effects (1) it allows Remote Supports to be regulated separately, without the relatively loose conditions, restrictions, and limitations of PERS or AT, and thus, appropriately, and (2) it recognizes the fact that, given the cost-effectiveness of Remote Supports to the state, Remote Supports services shouldn’t be capped similarly to AT or Environmental Mods. These two effects of separating Remote Supports as a service have very serious implications for workability of the service for state stakeholders, including individual HCBS participants.

Fourth, Indiana and Ohio, by allowing subcontracting with providers in addition to state contracting without residential provider affiliation, allow the broadest possible access to Remote Supports services. Individuals on Indiana’s Family Supports Waiver (FSW) often do not receive residential services or do not have a residential service provider. If Indiana only allowed for the subcontracting route, these individuals’ access to the service would be limited. However, by providing a path by which Remote Supports providers can contract with the state directly, they allow these individuals to choose to use the service if it is appropriate.

Finally, Indiana and Ohio’s implementation of Remote Supports into waiver services include provisions for ensuring the preservation of privacy of the individual, including provisions for informed consent of all residents within the home. Examples of these regulations for Indiana and Ohio can be found in the Indiana CIH Waiver Amendment document and Ohio Administrative Code 5123-9-35(D)(6), respectively.

Altogether there are seven key elements that Indiana and Ohio’s implementation of Remote Supports into their HCBS waiver possesses:

(1) Separate definitions for Remote Supports, AT, and other technology-based HCBS services.

(2) Provisions for Remote Supports providers to both subcontract with residential service providers to provide services to individuals the residential provider serves and to contract with the state to provide services to individuals who do not have a residential services provider, such as individuals on self-determination waivers, individuals in family homes, etc.

(3) Financial incentives for residential providers to adopt Remote Support services and push for their integration into individuals’ PCISPs.

(4) Regulations that mitigate the risks associated with Remote Supports services.

(5) Funding/reimbursement models that do not arbitrarily cap reimbursement for Remote Supports services.

(6) Funding/reimbursement models that do not combine reimbursement funds for Remote Supports with reimbursement funds for AT and other technology-based HCBS services.

(7) Provisions for informed consent and privacy considerations that support an individual’s right to privacy and to choose whether Remote Supports will include live video.

Examples of State Integrations that Restrict Benefits

In this section, the drawbacks of state integration attempts that do not possess the above properties will be outlined.

To begin, consider a state which has not separated Remote Supports from their Assistive Technology HCBS service definition or has combined it with other technology-based services to create an omnibus technology service. This inherently limits the state’s ability to regulate each discrete subservice at a waiver level because definitions, limitations, and approved provider requirements are set during waiver amendment periods. What’s more, states inherently limit their capacity to fine tune reimbursement amounts when technologies are lumped together. For example, PERS often cost around thirty to fifty dollars per month to operate. Reimbursement for PERS services significantly above that mark means the state is overpaying for those services. Similarly, Remote Supports can cost anywhere from two dollars to eight dollars per hour of services rendered. If a state’s reimbursement methodology caps the omnibus tech service reimbursement rate at forty dollars per month, then the individual is severely restricted in the number of hours of Remote Supports they can use.

Separating these services at once allows states to reimburse and regulate each one appropriately, which not only improves the safety of each constituent services but saves the state and CMS funds in the long term.

Secondly, states that do not allow Remote Supports providers to provide their services on a sub-contractual basis with residential providers, in addition to a state contracting arrangement. introduce obstacles to Remote Supports integration. For states with only subcontracting, individuals who are not associated with a residential provider are denied access to the service. For many states that only allow state contracting, suboptimal regulations (including provider enrollment processes designed for residential service providers, not Remote Supports providers) often present major administrative obstacles for Remote Supports providers.

For states to have parity among the populations they serve with regard to access to Remote Supports services and their benefits, both subcontracting and state contracting should be allowed. In the case of the former, regulations regarding the provisions of Remote Supports should still be in place to ensure the core components are addressed and safety of the individual is maintained. In state contracting situations, attention must be given to the fundamental differences between providers of Remote Support services and residential service providers. Provider enrollment processes and requirements, including required training for staff, often include items which are not applicable to remote service provision. Examples include water temperature regulation (in an individual’s home), hazardous and toxic chemical handling (in an individual’s home), approved restraints, and handling of bloodborne pathogens. Each of these training items do not apply to remote service provision, and thus should not be required of Remote Supports providers.

In addition to refining provider enrollment and training requirements to more appropriately fit the nature of Remote Supports services, we also urge states to understand the interstate nature of Remote Supports service provision. An RSP could, at any time, be supporting individuals from five different states. This is fundamentally different than most other service models. That means RSPs are required to take five different versions of Abuse, Neglect, and Exploitation training to satisfy each of the different states’ training requirements. We understand the necessity of this training but urge CMS to recommend that states accept other state’s training and training evidence as sufficient for their own training requirements. Without such interoperability, the growth of Remote Supports will continue to be hindered at the Remote Support provider level. Newly onboarded RSPs will be required to take ten, fifteen, or even twenty separate but ultimately equivalent training on common subjects such as Abuse, Neglect, and Exploitation, Rights of People with Disabilities, and so on.

Thirdly, many states do not include necessary regulations to ensure that the provision of Remote Supports is done safely. Key aspects of quality Remote Supports service definitions, including the necessity of a live monitoring station, requirements for redundant phone and internet connections, requirements for two-way audio or video communication, requirements for a backup generator, battery backups, and HIPAA-compliant IT systems, are often left out in the interest of removing barriers to technology integration. While we do agree that some of these requirements are not necessary for certain types of technologies/technology-based services, we urge states to include them for Remote Supports specifically. Other services, so long as they are separated out in the waiver, can be regulated according to their own needs. But the nature of Remote Supports, a service which connects individuals to RSPs in real time, requires that measures be taken to ensure that Remote Support systems have adequate uptimes and that, in the event of catastrophic failure, backup measures are in place to ensure individuals can receive in-person support on short notice. It is the presence of these key infrastructure requirements that have allowed Remote Supports to be successful as a service, and we urge CMS to include such requirements in their guidance to states about Remote Supports implementation.

Finally, there are two significant pitfalls that states fall into when it comes to how states define and reimburse for Remote Supports services.

Firstly, if it is understood that Remote Supports are a service that is intended to reduce reliance on in-person staff and that Remote Supports are, unit for unit, more cost-effective than residential staffing services, then it follows that there should be no cap on the number of hours which can be exchanged from residential services to Remote Supports. Ohio reimburses Homemaker, Personal Care (HPC) services at $23.34/hour and Remote Supports services with paid backup support (RS) at $10.24/hour. For every hour switched from HPC to RS, the state saves $13.10/hour. For just one individual exchanging 8 hours of HPC for RS daily, the annualized savings for the state are $38,252. Given this, the state of Ohio does not cap the number of units of RS that can be utilized, so long as it remains appropriate given a person-centered examination of the individual’s goals and intended outcomes.

Unfortunately, some states do cap Remote Supports services by placing the funds available to reimburse the service in the same bucket as funds for Assistive Technology, Environmental Modifications, etc. While it makes sense to cap AT funds, if we understand AT to be discrete devices aimed at improving functional capabilities, it does not, as we’ve demonstrated above, make sense to cap Remote Supports.

A second unintended consequence of putting Remote Supports and assistive technology monies in the same capped fund is that individuals are often forced to choose between one or the other. This is not necessary, and in fact restrictive to individuals. It is possible a person could need some AT devices, such as a screen reader, and also benefit from Remote Supports. Forcing them to choose between AT and Remote Supports puts non-competing and non-duplicative services into a competing framework.

Conclusion

Over the many years CAIRSS members have been providing Remote Supports services, we have experienced many different permutations of state efforts to implement Remote Support services and other technologies into their HCBS waiver systems. It is our collective belief that not all implementation efforts are equal, even though they are all well-intentioned.

As states, provider organizations, and other stakeholders finalize their transition into compliance with the HCBS Final Settings Rule, it’s important that technology-based services are available as a viable and safe option to increase an individual’s choice of setting. The capacity for Remote Supports services and others to assist in this transition should not be constrained by the way states implement these services in their HCBS waivers.

The Centers for Medicare and Medicaid Services is in a unique position to offer federal guidance on Remote Supports integration to help avoid past mistakes and to provide states the information they need to competently integrate the service in a way that removes unnecessary barriers for individual use of the service, removes obstacles for service provision, and promotes competition among Remote Support providers to ensure that quality and price remain competitive and advantageous to states.

Recommendations

1. CMS formally recommends all states offer Remote Supports as an allowable service within their HCBS waivers to alleviate the effects of the staffing shortage and improve outcomes for participants.

2. CMS creates and promulgates a definition for Remote Supports services.

3. CMS creates guidelines related to the implementation of Remote Supports service definitions to remove administrative and operational barriers to service and ensure equal access to Remote Supports services among all HCBS participants.

4. Relating to the above recommendation, CMS urges states to accept interoperable training standards to reduce training redundancies.

References

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Larson, S.A., Tolbize, M.S.A., Kim, O., and York, B. (2016). Direct Support Professional Turnover Costs in Small Group Homes: A Case Study. Minneapolis: University of Minnesota, Research and Training Center on Community Living.

National Core Indicators. (2022). National Core Indicators Intellectual and Developmental Disabilities 2020 Staff Stability Survey Report. https://www.nationalcoreindicators.org/resources/staff-stability-survey/

Richter, B. (2021, November 11). What are Remote Supports? - CAIRSS . CAIRSS. Retrieved March 7, 2023, from https://www.cairss.org/positions/project-four-2jzmp

Tanis, S. (2021). (rep.). Perspectives from Intellectual and Developmental Disability Services Providers Across the Nation. ANCOR.

Tassé, M. J., Wagner, J. B., & Kim, M. (2020). Using technology and remote support services to promote independent living of adults with intellectual disability and related developmental disabilities. Journal of Applied Research in Intellectual Disabilities, 33(3), 640–647. https://doi.org/10.1111/jar.12709

Wagner, J. B., Tassé, M. J., & Ornan, G. (2022). Implementation of Remote Support Services: pre‐covid ‐19. Journal of Policy and Practice in Intellectual Disabilities, 19(4), 340–349. https://doi.org/10.1111/jppi.12420

Refining Technology Definitions

Background

In the last two decades, there has been an explosion of technology integration into services and supports for individuals with disabilities. The addition of higher-technology options to the traditional pantheon of assistive technology devices and the development of more complex technology-based services, such as remote supports, has fundamentally changed the world of disability services.

CAIRSS could not be happier about the greater involvement of technology in disability services. Technology not only addresses chronic issues such as the national direct care staff shortage and limited funding for individuals trying to receive supports, but they have also demonstrated a capacity to improve outcomes for the individuals served by allowing them to access greater independence at home, work, and play.

Unfortunately, as is the case with the introduction of any new service, there have been some obstacles along the way. One example we’ve seen has been the lack of coherent and standardized definitions for the various emerging services. There are numerous terms for the same service, and different services being reimbursed and regulated under the same terms. The problem is both intra- and interstate.

The state-based model for disbursing HCBS waiver benefits has given rise to 50 separate conceptions of technology and its use as a service for people with disabilities. While no doubt each of the persons in working to add technology have individuals’ best interests at heart, there is no established national framework of concepts they can draw upon as they build policies, regulations, and reimbursement methods. The effects of these disparities in definitions, terms, and reimbursement structures proves detrimental to technology integration at many levels.

For the individual and family members doing research about technology services, the information gathered can be extremely disorienting. In one state assistive technology is not provided, but adaptive aids are. However, some items and services allowed under the adaptive aids service are identical to those defined elsewhere as assistive technology. Any effort to understand, let alone evaluate, different technology services and supports for themselves or their loved one is bogged down by ambiguities and homonyms.

For providers, especially providers of technology, the lack of a coherent set of definitions presents problems as well. For one, technology providers may be allowed to provide a piece of technology or service under the service definition designed by one state, but not another, even if the services have identical names. Secondly, their efforts to engage with stakeholders, such as family members and individuals, is hindered by the need to change their use of certain words to match whatever terms the state has adopted.

We must not forget the states in all of this either. Departments administering HCBS waivers suffer from this confusion of definitions as well. In addition to indirectly being affected by the problems for their provider and family stakeholders, state funds are affected.

One state recently implemented remote supports but also reimburses PERS and simple phone calls under that service definition. Presumably this means a PERS provider could be reimbursed at the same rate as a remote supports provider. For those unfamiliar with the difference: PERS (personal emergency response system), staff only respond to crisis calls from individuals, whereas remote support professionals are more actively engaged minute to minute with the individual. This difference in engagement means providers of remote supports are spending more for every hour they’re being reimbursed, whereas PERS units have much lower per-service-hour costs. Why should states care? Because they’re losing money. PERS units can and have been reimbursed at significantly lower rates in other states, states who understand PERS is separate and distinct from remote supports. Money the state could save separating RS and PERS services could be spent providing more services to individuals on waitlists.

Additionally, states looking to increase rates of technology utilization by introducing new tech-based services can be hindered in their efforts by this confusion about terminology. For example, if a state does not appreciate the difference between remote supports services and PERS, it will not appropriately regulate and reimburse these activities in a way that incentivizes provider organizations to participate. To reimburse remote supports at an existing PERS rate reveals is to reveal a fundamental misunderstanding of the core elements of both services.

It is important for states to understand and appropriately codify conceptions of these discrete technology services if we are to enjoy the full benefits of what technology has to offer people with disabilities. Any equivocation or confusion serves only to hinder access to life-changing opportunities for the individuals serve.

These are just a few examples intended to illustrate the negative effects of not having a robust, national set of definitions about technology. Without a concentrated movement toward interstate cooperation on definitions, we will continue to experience these roadblocks to greater implementation, and, consequently, enjoy fewer of the potential benefits of full technology integration.

To begin to address this issue, we at CAIRSS have compiled a set of definitions we believe capture the core differences of technology solutions and services. We hope these definitions will serve as a basis to clarify and refine terms for states which have already implemented technology services and those which have not yet integrated technology.

Enabling/Supportive Technology

“Enabling and supportive technology is the umbrella term used to describe all aspects of technology which are and may be used to support an individual with a disability. Assistive technology, as defined by the AT Act of 1988, falls into this category, as does remote supports, remote alert systems, PERS, telehealth services, environmental/home modifications, and vehicle modifications.” - CAIRSS

Assistive Technology

“Any item, piece of equipment, or product system, whether acquired commercially, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities.” – (29 U.S.C. Sec 2202(2))

Remote Supports

“Remote supports is a technology-based service that allows trained, remote support professionals (RSPs) to deliver live support to an individual at a remote location. Its primary goal is to foster an individual’s independence while maintaining their safety as they live in the community. Remote supports are delivered by awake, alert RSPs whose primary duties are to provide remote supports from the provider’s secure facility. To ensure safety and HIPAA compliance, this Remote Supports facility should have appropriate, stable, and redundant connections. This should include, but is not limited to; backup generators, multiple internet service connections, battery backups, etc. Remote supports should always be selected as the result of decisions made by the individual and their team. Remote supports must be incorporated into the individual’s personalized service plan and must be executed in a person-centered fashion. Remote supports are not intended as a wholesale substitute for in-home direct support professionals. They are intended to replace some staff hours for individuals who do not require in-home staff at all times, but still need some support.” - CAIRSS

Remote Alert Systems

“Remote alert systems are technology setups which combine discrete pieces of technology (such as sensors) into a system which sends information (such as sensor alerts) directly to DSPs, provider professionals, or natural supports like family members. These systems are designed to link the actions and events in an individual’s home to a DSP or natural support. Remote alert systems function similarly to remote supports in that both often capture and send sensor information from the participating individual’s home. However, they differ in that remote alert systems may not utilize awake, alert RSPs or have the technical redundancies built in like many remote support services.” - CAIRSS

Virtual Supports

“‘Virtual Supports’ is an umbrella term that encompasses the service delivery method whereby DSP-backed, in-person services are provided through technology. In the wake of COVID-19 era Appendix-K flexibilities, many states began allowing traditionally in-person services to be accomplished virtually. Virtual Supports does not refer to any specific in-person service, but the method of providing any service virtually, without a physically present staff person.” - CAIRSS

Personal Emergency Response System (PERS)

“PERS is an electronic device that enables participants to secure help in an emergency. They participant may also wear a portable ‘help’ button to allow for mobility. The system is connected to the participant’s phone and programmed to signal a response center once a ‘help’ button is activated. The response center is staffed by trained professionals.” - Indiana HCBS Waiver Definition

Telehealth/Telemedicine Services

“Telehealth is… the use of electronic information and telecommunication technologies to support long-distance clinical health care, patient and professional health-related education, health administration, and public health.” - Health Resources & Services Administration.

The central difference between remote supports and telehealth is the clinical nature of the latter. While remote supports are a supportive & habilitative services, telehealth focuses on facilitating clinical activities between a patient and healthcare provider.

Environmental/Home Modifications

“Environmental/Home modifications are deliberate alterations made to an individual’s living environment in order to make said environment more accessible to the individual or to facilitate the execution of necessary tasks for daily living. Examples of environmental/home modifications may include, the installation of wheelchair ramps, accessible bathtubs, or grab bars, or the widening of doorways.” - CAIRSS

Vehicle Modifications

“Vehicle modifications are deliberate alterations made to a vehicle in order to make that vehicle more accessible to an individual with a disability. This could include installing a wheelchair lift, removing seating to accommodate a secure wheelchair position, or installing grab bars.” - CAIRSS

On Regulatory Challenges to RSP Training & Onboarding

This article is intended to address certain challenges remote supports (RS) providers face with remote support professional (RSP) training and onboarding requirements. Like all other HCBS waiver provider agencies, RS providers are required to fulfill certain obligations and requirements in order to establish compliance and operate in good faith. These regulations are intended to preserve the quality of the services rendered and ensure the continued safety of the individuals served. For the most part, these regulations accomplish their objective. However, the unique RSP work situation poses novel challenges. In this article, CAIRSS will outline two major challenges and propose solutions.

The first challenge arises because of the physical distance between the RSP and the individual. Though RSPs provide real-time support to the individual, they do so remotely. They never have direct contact with the individuals to whom they provide services. (While it is possible that, during the course of a remote support period, backup staff may be dispatched to the home to assist the individual, the remote support professional does not - in the vast majority of cases - simultaneously provide that backup.) What’s more, if a smaller RS provider agency used the same employees as RSPs and backup DSPs, that employee would be appropriately subject to regulations and requirements applicable to DSP staff who have direct contact with the individual. When states introduce RS services, many current training/onboarding regulations and requirements for DSPs are copied over to form RS regulations without careful consideration of the difference between direct and remote support.

For example, Ohio, where remote support has been an active waiver service for ten years, requires RSPs to undergo training for universal precautions such as infection control and disposal of bodily waste.* While it is clear that training is necessary and useful for staff in direct contact with an individual served, it does not apply to staff whose work is entirely remote. This pattern remains with other states, including Missouri. The MO DD Waiver Manual outlines the training requirements for staff performing Personal Assistance services (under which remote support services are billed and regulated).† These requirements include CPR, first aid, and non-violent crisis intervention.‡ All of this training is applicable only to staff who are in direct contact with the individual served, which categorically excludes RSPs.

The enforcement of these regulatory requirements has been understanding, yet inconsistent. RS providers remain subject to auditors’ discretion and understanding of the remote nature of RSP work. Without formal separation of regulations and requirements for DSPs and RSPs, RS providers will continue to face unnecessary challenges as it relates to RSP onboarding and training. Given the national DSP shortage and increased demand for remote supports, these barriers should be removed to allow RS providers to more efficiently onboard new RSPs. Additionally, states working to implement remote supports as a waiver service should understand the difference between direct and remote care, and form regulations in accordance with that knowledge. 

The second major challenge for RS providers when it comes to RSP training and onboarding is the interstate nature of service provision. Because RSPs can provide simultaneous support to different individuals remotely, it is often the case that one RSP will, during a given shift, support people from different states. This contrasts with the work of DSPs, which typically occurs within one state, no matter how many individuals the DSP serves in each shift. Because of the variation in location of the different individuals served, RS providers are required to administer training in accordance with several state requirements simultaneously.

While many of these onboarding and training aspects are important and non-duplicative (e.g. training on state-specific incident reporting, some background checks), some are redundant and form unnecessary duplications of time and labor for little or no added gain. To use the examples referenced above, the MO DD Waiver Manual requires “training, procedures, and expectations related to the PA in regards to following and implementing the ISP,” “Training in abuse/neglect… (and) confidentiality,” and “Training in communications skills in understanding and respecting individual choice and direction, cultural and ethnic diversity, personal property and familial and social relationships in handling conflict and complaints.” All three of these training items are represented in the 8-Hour training course supplied by the Ohio DODD. Additional course materials which are duplicative include: rights of people with disabilities, self-determination of the individual, explanation of intellectual and developmental disabilities, roles and responsibilities of RSPs, people-first language, person-centered services, trauma-informed care, protecting the health and welfare of people with I/DD, and community integration.

In practical terms, this duplication of training materials and onboarding requirements means that during the hiring process more time is spent repeating information, testing, and training. This can lead to information overload and fatigue among new RSP hires, prolong the training period, and force more RSPs out of the pipeline before they are able to effectively deliver services. CAIRSS agrees that all the aforementioned information is helpful and necessary for best-practice execution of remote supports, but we also believe that unnecessary redundancy should be avoided where possible. As mentioned earlier, we understand that certain aspects of training and onboarding will always need to be accomplished on a state-by-state basis. Incident reporting remains a prime example, as it varies from state to state. But information about the nature of disabilities, the rights of people with disabilities, person-centered planning, community inclusion, etc., should remain the same among different states. We believe this information can and should be condensed into a state-independent, fully compliant training program which is formally acknowledged by each state that has remote supports as a waiver service.

We also understand that this service is relatively new, and that many states simply imported what was used for DSPs. What we’ve learned through our many years of experience is that these regulations don’t often accommodate these two unique aspects of RSP work, it’s remote and interstate nature. CAIRSS believes that the formation of an interstate consensus on basic elements of RSP work, whether it be a formal adoption of multi-state training or a state’s willingness to accept another state’s trainings as acceptable, would go a long way to eliminate these barriers and allow for improved RSP onboarding and training. This optimization would allow RS providers to accommodate more of the growing demand for remote support services, which would improve outcomes for the people we’re all passionate about serving.

*OAC 5123-9-35(C)(4) referencing OAC 5123:2-2-01(D)(17)(g)

† As of June 2021

‡MO DD Waiver Manual Personal Assistant Training Requirements p82-83

Core Remote Supports Service Definition

Remote Supports is a technology-based service that allows trained remote support professionals (RSPs) to deliver live support to an individual at a remote location. Its primary goal is to foster an individual’s safety to allow them to live more independently in the community.

Remote Supports are delivered by awake, alert remote support professionals whose primary duties are to provide remote supports from the provider’s secure remote supports facility. To ensure safety and HIPAA compliance, this facility should have appropriate, stable, and redundant connections. This should include, but is not limited to, backup generators, multiple internet service connections, battery backups, etc.

Remote Supports should always be selected as the result of decisions made by the individual and their team. Remote supports must be incorporated into the individual’s personalized service plan, and must be executed in a person-centered fashion.

Remote Supports are not intended as a wholesale substitute for in-home direct support professionals. They are intended to replace some staff hours for individuals who do not require in-home staff, but do still need some support. Remote supports offer relief to DSP providers facing the nationwide shortage of qualified staff.