Resource: Overnight support for people in their own home

Page posted: 10/6/23

This resource helps lead agencies (including contracted case management partners) develop support plans with people who live in their own home and may have a need for overnight support. It includes information about services through:

· Alternative Care (AC).

· Brain Injury (BI) Waiver.

· Community Access for Disability Inclusion (CADI) Waiver.

· Community Alternative Care (CAC) Waiver.

· Developmental Disabilities (DD) Waiver.

· Elderly Waiver (EW).

· State plan personal care assistance (PCA).

What is the process to select and authorize overnight support?

Selecting a service starts with the person’s informed choice. To make an informed choice, the person must receive the tools, information and opportunities they need to understand their options. They must receive this information in an accessible format and manner that meets their needs. The informed decision-making process must occur at least annually and whenever the person’s needs or preferences change.

When developing the person’s support plan, the lead agency must base the selected service, support instructions, service frequency and other aspects of service delivery on what is important to and for the person. Each service must address the person’s assessed need, and the lead agency must document that need in the support plan for each specific service.

The section of the support plan in which the lead agency documents information depends on the person’s specific need and how that need will be addressed. The lead agency can document the person’s need in any of the following sections of the support plan:

· Support instructions.

· My plan to address safety needs.

· Goals.

· My action item(s).

The person does not need to “fail” at using one service before trying another option. Services should:

· Address the person’s needs in a way that promotes independent living.

· Be provided in the most integrated manner, minimizing disruption of the person’s daily routines, rituals and relationships.

· Be consistent with the person’s choice and preferences.

For some people, this might mean assistive technology. For others, this might mean awake night supervision. DHS provides a variety of services and supports to meet people’s wide range of needs.

Support planning considerations

A person’s support plan must include the correct amount of services required to meet their assessed needs. If a person chooses to live with roommates, they must have a separate support plan specific to their service needs.

To identify how much and what type of services a person needs, lead agencies should consider asking:

· What are the person’s assessed needs (e.g., activities of daily living, instrumental activities of daily living, behavioral supports, health support needs)?

· What services — formal or informal — can support the person’s assessed needs?

· What technology options could support the person to live in their own home?

· How many hours per day does the person need direct staffing support? At what times of the day do they need it?

· Has the person chosen to share services? Which ones? When and how often?

· Could multiple services (instead of one service) support the person throughout the day?

· Could multiple providers (instead of one provider) deliver the services in which they specialize?

Choosing to share services

A person has the right to choose where they live and whether they live with roommates or by themselves. When a person chooses to live in their own home with roommates, each roommate who receives services must have a separate support plan specific to their service needs.

Shared staffing means one or two staff members work with all roommates at the same time. When creating a person’s support plan, the case manager cannot assume shared staffing will be the primary service delivery method. Shared staffing is similar to community residential services, which requires the home be licensed as a community residential setting (refer to CBSM – Community residential services).

The person chooses their provider(s) when they develop their support plan. They do not have to choose a specific provider to live in their own home, nor do they have to choose the same provider as their roommate(s). The person and their roommates can choose to have the same provider or different providers for the same service. For more information about this policy, refer to CBSM – Requirements for a person’s own home.

If all people who live in the home choose the same provider, the case manager cannot default to using shared staffing. Each person’s plan must describe:

· How the person made an informed choice to receive shared staffing.

· How shared services meet the person’s needs and preferences.

· The person’s specific support needs met by individual staffing.

· The person’s specific support needs met by shared staffing.

· When the person receives individual staffing.

· When the person receives shared staffing.

It is not typical for a person living in their own home to receive shared staffing all day, every day. Shared staffing might make sense for a few hours, multiple days a week, when each person works on similar activities or skill-building opportunities covered by the service.

What is the best way to talk about overnight support with a person and their family?

The case manager must ask questions to help the person and their family make informed choices about overnight support, including balancing risk. Some questions that may help start the conversation include:

· Does the person need support overnight?

· What overnight support has the person tried in the past? What worked? What did not work?

· Are informal supports available to support the person overnight?

· What technology options could support the person overnight?

· When the person previously received overnight supports (asleep or awake) in their own home, did they use supports in the middle of the night? If so, what where those supports? How often did the person use them? Was there a pattern?

· Does the person need to receive an in-person response within a specific amount of time?

· Would having someone available by phone or two-way video be enough most of the time?

· How could the person’s overnight support needs be met in another way?

· Have the person’s assessed needs changed? Has the person had any life events that result in a change to their support plan?

Which services could meet a person’s overnight support needs?

Many services are available to support a person who lives in their own home. The case manager must ensure the person’s services follow all waiver plan requirements and requirements on CBSM – Requirements for a person’s own home.

A person who needs overnight support in their home has many options, including the following services:

1. 24-hour emergency assistance:

· Available through: BI, CAC, CADI and DD.

· Description: This service includes on-call counseling, on-call problem solving and/or immediate response to provide a person access to supports to address a medical or personal emergency.

2. Assistive technology (waiver service):

· Available through: DD.

· Description: Assistive technology can replace or supplement a person’s staffing and ensure they can control and access their home.

· Note: Assistive technology is available on AC, BI, CAC, CADI and EW through specialized equipment and supplies, described below.

3. Caregiver living expenses:

· Available through: BI, CAC, CADI and DD.

· Description: This service pays for the room and board for a live-in caregiver. As part of this service, a person and their live-in caregiver can develop a plan for overnight support the person needs as part of their support plan.

4. Consumer directed community supports (CDCS) personal assistance:

· Available through: AC, BI, CAC, CADI, DD and EW.

· Description: This service option offers a person the ability to self-design their services to create support that will meet their assessed needs. CDCS policy does not include limits on the time of day support workers may work.

5. Environmental accessibility adaptations – home modifications:

· Available through: AC, BI, CAC, CADI and EW.

· Description: This service provides physical adaptations to a person’s primary home to ensure their health and safety or enable them to function with greater independence.

6. Night supervision:

· Available through: BI, CAC, CADI and DD.

· Description: This service provides asleep or awake staffing for a person who has an assessed area of need overnight for positive support programming, skill development support, assistance with activities of daily living (ADLs) or assistance with instrumental activities of daily living (IADLs).

7. Personal care assistance (PCA):

· Available through: AC, state plan or extended PCA on BI, CAC, CADI, DD and EW.

· Description: This service provides awake staffing for a person overnight who requires covered personal care services.

8. Personal emergency response systems (PERS):

· Available through: AC, BI, CAC, CADI and EW.

· Description: This service covers both (1) an electronic device typically worn as a pendant or bracelet that includes an alert or panic button the person can press in the event of a fall or other emergency and (2) installation and monitoring of the device.

9. Specialized equipment and supplies (includes assistive technology):

· Available through: AC, BI, CAC, CADI and EW.

· Description: This service provides devices (including assistive technology), controls, medical appliances or supplies specified in the person’s support plan. Assistive technology can replace a person’s staffing and ensure they can control and access their home.

· Note: Assistive technology is available on DD through the assistive technology service, described above.

How can a person use assistive technology and/or remote support for overnight support?

A person can use assistive technology and remote support to support their independence in a variety of ways, including, but not limited to, supporting their overnight needs.

When discussing assistive technology and remote support for the person’s overnight needs, the lead agency should consider that the person:

· May choose a combination of assistive technology and remote support to supplement overnight in-person staffing.

· May choose to rely solely on assistive technology and remote supports for their overnight needs.

· Should have overnight supports that support their assessed overnight needs and prioritize their preferences and choices.

Assistive technology is not intended to replace in-person care when the person needs or prefers in-person care. However, the person may use it to supplement in-person care if both of the following are true:

· Assistive technology meets the person’s needs.

· The person makes an informed choice to receive it.

How does a person on AC or state plan PCA receive overnight support?

PCA cannot pay for time when staff are asleep. PCA only pays for covered services, and sleeping is not a covered service. For information about covered PCA services, refer to PCA Manual – Covered services.

PCA can pay for time when:

· The person is asleep, and staff actively perform a covered service.

· The person is awake, and staff actively perform a covered service.

How does a person on CDCS receive overnight support?

The lead agency is responsible to evaluate the person’s need for overnight support on CDCS that fits within the personal assistance category. The lead agency must provide oversight and ensure the person’s CDCS plan identifies the waiver service that staff will provide during overnight support. Staff must actively be providing a covered service. CDCS cannot pay for time when staff are asleep.

CDCS can pay for time when:

· The person is asleep, and staff actively perform a covered service.

· The person is awake, and staff actively perform a covered service.

The lead agency should consider many things when the person uses CDCS for overnight supports, including cost effectiveness. The person’s CDCS budget may not be large enough to accommodate this level of staffing support.

Additional information for BI, CAC, CADI and DD

When should the lead agency authorize night supervision instead of PCA for overnight assistance with ADLs?

The lead agency should authorize PCA when PCA can meet the person’s needs. The person does not need to “fail” at using PCA before trying another service option.

For information about covered PCA services, refer to PCA Manual – Covered services.

The scope of night supervision is broader than the scope of PCA. Night supervision is the assistance and supervision of the person overnight, including assisting with ADLs. If the person has a need for both assistance and supervision, the lead agency should authorize night supervision.

Note: Night supervision is not available on AC and EW.

How do lead agencies transition people to night supervision for asleep staffing?

In 2021, DHS provided temporary guidance for overnight in-home supports for people on the DD Waiver who had supported living services (SLS) daily in their own home before the Waiver Reimagine service streamlining. Now that the asleep option for night supervision is available, people on the DD Waiver must transition to night supervision (if needed) at their renewal. For additional information, refer to the Jan. 4, 2023, eList announcement.

Note: In-home asleep overnight staffing is not an option for people on AC or EW.

Who can provide overnight supports to minor children?

Children younger than age 18 on any waiver can receive overnight support by staff through the following services:

· 24-hour emergency assistance.

· CDCS personal assistance.

· Night supervision.

Children younger than age 18 can also access assistive technology services through the assistive technology service (DD) or specialized equipment and supplies (BI, CAC and CADI).

Parents of minors cannot be paid to provide night supervision or 24-hour emergency assistance to their children. Under CDCS, parents of minors can be paid to provide services for their children (refer to How does a person on CDCS receive overnight support?).

Parents of adult children can be paid to provide night supervision or 24-hour emergency assistance to their adult child when they meet the service requirements. When a parent lives with the adult child (or the adult child lives in the family home), the parent cannot be paid for time the parent is asleep.

How do lead agencies support the person and their family during service transitions?

Each person has different factors that contribute to their quality of life. Systems that value quality of life are built on and driven by a desire to understand, respect and honor each person’s values. These factors are especially important to consider during transitions.

Times of transition can be difficult and stressful. There are many uncertainties, and the fear of failure can outweigh the rewards of success.

Clear, direct and honest conversations should happen between the person, their case manager and their support team. These conversations can include discussions about family-centered supports, right to risk and dignity to risk.

Family-centered supports

When a person transitions to live in their own home, their family might experience a significant change in their world. Their child has become an adult and now has the right and autonomy to take control over their life. For a parent or caregiver, this shift creates a change in mindset, from parenting a child to having a relationship with an adult child. To ensure everyone’s needs are met, waiver services can support this natural and gradual separation between parent/caregiver and child.

Case managers can use the following tools and services before and throughout major life changes to provide people and their families a roadmap to navigate new and unfamiliar territory:

· Disability Hub MN – Charting the LifeCourse: Tools and guides for any stage of life are tools to set goals and a vision for the person’s best life.

· DHS – Person-centered practices can help the person communicate and explain their dream for the future. A person can use family training and counseling for person-centered planning facilitation, as described on CBSM – Family training and counseling. The case manager can use code S5110 to authorize family training for person-centered planning facilitation. For more information, refer to DHS – Frequently asked questions about formal person-centered planning.

· CBSM – Family training and counseling can support families through changes. Family counseling may be an important step to ensure the person and their family have the skills and tools for communication techniques, conflict management, coping strategies, family roles, problem solving, relationships and resilience-building.

· DHS – Housing Stabilization Services can support the person to continue living in their own home.

Right to risk and dignity to risk

Discussions with a person about risk may include many perspectives, from both formal and informal supports. Each person involved may have a different understanding of the benefits of self-determination.

Lifelong learning and independence come from opportunities for people to make their own choices. Research shows people with disabilities who have greater opportunities for self-determination:

· Live more independently.

· Learn more skills.

· Are healthier.

· Are well adjusted.

· Are better able to identify and resist abuse.

Living in the community comes with expected risks, regardless the level of supports the person may need. CBSM – Guide to encouraging informed choice and discussing risk provides guidance about when and how to discuss with people their right and ability to make informed choices that may include risk. A person may use supported decision-making to help them make choices.

Additional resources

DHS – Ethical dilemmas: Right to take risks versus right to be safe (video)
DHS – Introduction and guide to supported decision-making (video playlist)
Disability Hub MN – Decision making
Disability Hub MN – Charting the LifeCourse: Tools and guides for any stage of life
Volunteers of America – Center for Excellence in Supported Decision Making (CESDM)
CESDM guide for supported decision-making (PDF)
CBSM – Community residential services
CBSM – Requirements for a person’s own home
CBSM – 24-hour emergency assistance
CBSM – Assistive technology
CBSM – Caregiver living expenses
CBSM – Environmental accessibility adaptations (EAA) – home and vehicle modifications
CBSM – Night supervision services
CBSM – Personal care assistance (PCA)
CBSM – Personal emergency response systems (PERS)
CBSM – Specialized equipment and supplies
CBSM – Family training and counseling
CBSM – Guide to encouraging informed choice and discussing risk
CDCS – Personal assistance
PCA Manual – Covered services
Jan. 4, 2023, eList announcement
DHS – Person-centered practices
DHS – Frequently asked questions about formal person-centered planning
DHS – Housing Stabilization Services

Legal authority

Powers and duties for someone under guardianship (Minn. Stat. §524.5-313)
Bill of rights for a protected person (Minn. Stat. §524.5-120)