ICF/IID Program-Background and History
Prior to 1971, facilities for the people with intellectual disabilities (formerly, "mental retardation") developmental disabilities were financed solely by state, local and private funding. Dramatic changes were the order of the day, compelling Congress and the Nixon administration to act.
An amendment to the Social Security Act passed and enacted into law that year, establishing special facilities financed with federal dollars. These facilities were called "Intermediate Care Facilities for the Developmentally Disabled" or ICF/DD. Today, ICF/IID form a long-term care and training delivery system for individuals with intellectual and developmental disabilities (ICF/IID). The individuals are also commonly referred to as “clients,” “residents”, “people”, “persons we support”, or simply “individuals”.
Changes and improvements in ICF/IID support and training services have created one of the most progressive and technically advanced programs anywhere in the world. For residents, quality of life has improved dramatically, as access and choice have become hallmarks of the ICF/IID program. Support and training programs now provide them with increased opportunities to live in more home-like, less restrictive settings and, to the extent possible, to become a more integral part of their communities.
-ICF/IID Services and Goals-
ICF/IID provide a wide variety of services based on client needs, which vary according to age and level of intellectual and developmental disabilities. In addition, to providing a home-like environment with personal and support services, ICFs/IID serve as teaching/training facilities that make use of sophisticated client assessment tools to determine clients' medical, dietary, psychological and social needs. As you can see, there is a range of services offered by ICF/DD to meet the complex needs of clients while enhancing their quality of life.
Many individuals reside in ICF/IID from youth until old age, which means that these facilities become a true home and staff become a second -- and sometimes the only -- family for some residents.
ICFs/IID vary from facility to facility and state to state, although they all bound by federal regulations. Despite facility variations, a common goal among facilities is to assess what individuals are capable of doing, to help them maximize their potential, and to do so with professionalism and compassion. This comprehensive approach to helping individuals acquire skills necessary for maximum independence and to helping them maintain optimal functioning or "active treatment." Active treatment, the foundation of the ICF/IID program, is discussed in detail in the following pages.
-Levels of Intellectual Disabilities-
Levels of intellectual disabilities have been described according to four main categories -- mild, moderate, severe and profound -- which are based on IQ scores and some assessment of adaptive skills. The following four levels and ratings according to the following IQ measurements:
Mild: IQ of 50-70
Moderate: IQ of 35-49
Severe: IQ of 20-34
Profound: IQ below 20
The majority of the people we support fall under the profound range. The American Association on Mental Deficiencies established these categories in 1983. Now known as the American Association on Intellectual and Developmental Disabilities, the Association has eliminated the above categories in favor of an emphasis on individualized assessments supplemented by IQ scores. However, Centers for Medicare & Medicaid Services (CMS) still uses these categories in providing data on individuals IID/DD, and for this reason, the categories are used in this document to describe clients.
Federal Medicaid guidelines define intellectual disabilities as significant sub average general intellectual functioning resulting in or associated with concurrent impairments in adaptive behavior and manifested during the developmental period.
Significant subaverage intellectual functioning is defined as measured intelligence, commonly expressed as I.Q. of 70 or less.
Impairments in adaptive behavior refer to the inability to perform personal and interpersonal functions at age-appropriate levels.
The developmental period is the period from conception to age 18.
Individuals with related conditions are those who have a severe, chronic disability that meets all of the following conditions:
Attributable to: cerebral palsy or epilepsy or any other condition, other than mental illness, found to be closely related to Intellectual Disability/Developmentally Disabled because this condition may result in impairment of general intellectual functioning or adaptive behavior and requires treatment of services similar to those required for those persons.
Manifested before the individual reaches age 22 (Federally) and 18 (State of Florida). Likely to continue indefinitely. Results in substantial functional limitation in three or more of the following areas of life activity: self-care, understanding, and use of language, hearing, mobility, self-direction, capacity for independent living (42CFR, Section 435.1009)2
Most individuals living in ICFs/DD have severe to profound intellectual disabilities and are likely to have multiple disabilities and impairments, such as cerebral palsy, epilepsy, speech/language impairments, and hearing and visual impairments.
-Trends in Size and Institutional Status of Facilities Serving People with Intellectual Disabilities and/or Developmentally Disabled Population-
As of 2011, all 50 States have at least one ICF/IID facility serving over 100,000 individuals with intellectual disabilities and other related conditions. The trend in caring for individuals with IID/DD over the last 30 years has been marked by a dramatic shift from large state-run institutions to smaller, privately run facilities. By federal definition, a large facility is defined as one that houses more than 15 beds, and a facility with fewer than 15 beds is considered small. Typically, large facilities are state-run, averaging 119 beds nationally. According to CMS, ICFs/ID are considered the most comprehensive benefit offered by Medicaid.i
Today, a strong deinstitutionalization trend is moving beyond the shift from public to private facilities. With the introduction of the Home and Community Based services (HCB) programs were established under Section 1915(c) of the Social Security Act, offering states the option of requesting waivers for individuals who otherwise would receive services in a Medicaid-approved institution, such as an ICF/IID. "The intent of the law was clearly to help States provide options to persons who prefer non-institutional care. It was not to mandate that ICF/IID clients who are eligible for institutional care be placed in alternative home and community-based settings against their will. The law allows for such placements when States make it available and when clients choose it."
In comparsion to ICFs/IID the HCB program is viewed as the more cost effective option. In 2014, 53% of all Medicaid long term care spending was on home & community based services.ii Furthermore, the Florida Medicaid funding in 2018 for ICFs/IID was $269 million compared to the over $1 billion annually for Home Community Based Services. In effect, there has been a push towards eliminating ICF/IID programs all together, and in some cases ICF/IID facilities have already converted to HCB waiver services. However, these waiver programs do not require federal oversight or the rigorous attention to individual training and support programs currently required for ICFs/IID. As a result, the HCB waiver program does not guarantee the level of care currently provided to individuals with intellectual disabilities and other related conditions by ICFs/IIDs.
-ICF/IID Emphasis on Resident Outcomes-
The Center for Medicaid Services (CMS) oversees the ICF/IID survey protocol and issues revisions and updates regulations as necessary. The survey protocol calls for an outcomes-based, customer-focused approach to facility surveys. This approach emphasizes customer responses and staff performance rather than a review of facility records. While there are eight conditions of participation with which facilities must comply, the survey process stresses four of those categories of participation: active treatment services, client protection, client behavior, and health care services.
A general understanding of these four general categories of participation is crucial to understanding the basic ICF/IID program. Summarized below:
Category 1: Active Treatment
To be certified to receive Medicaid funding, an ICF/IID must meet federal standards for 24-hour health care and continuous individualized active treatment for residents. Active treatment is the cornerstone of the ICF/IID program and involves a comprehensive team approach to teaching residents critical skills and behaviors. In general, the goal of the active treatment requirement is to assure that individuals acquire behaviors that help them to function as independently as possible, given their disability.
Individuals admitted to ICFs/IID must need and be receiving active treatment services. Before admitting a client, facilities conduct an evaluation, which includes background information and assessments of the individual's functional, developmental, behavioral, social, health and nutritional status. The purpose of the evaluation is to assure that the facility can meet the client's needs and that the client will benefit from placement in the facility.
Within 30 days following admission, facility interdisciplinary teams are required to perform accurate assessments or reassessments as a supplement to the pre-admission evaluation. This assessment must take into consideration the client's age and the implications for active treatment.
The assessment must also:
- • Identify the problems, disabilities, and their causes.
- • Identify the client's developmental strengths.
- • Identify the client's developmental and behavioral management needs.
- • Identify the client's need for services without regard to the actual availability of services needed
- • Include physical development and health, nutritional status, sensorimotor development, affective development, speech and language development, auditory functioning, cognitive development, social development, adaptive behaviors or independent living skills necessary for the client to be able to function in the community, and, as applicable, vocational skills.
Individual Program Plan (IPP) and the Interdisciplinary Team (IDT)
All clients must receive an individual program plan developed by an interdisciplinary team that represents a range of professions, disciplines, or service areas. The team members must be able to identify the client's needs and design appropriate programs to fulfill them. The IPP must be developed within 30 days after admission.
For some clients, their goals may be as basic as maintaining or avoiding loss of a particular skill. For others, their goals may be more advanced, such as managing their own bank account.
Implementation of the Individual Program Plan
Once the interdisciplinary team has developed the IPP, clients must receive a continuous active treatment program consisting of needed interventions and services. These interventions and services must accomplish the objectives of the IPP. All staff who work with the client must implement the clients’ IPP.
The active treatment process also calls for review and revision of the IPP by a Qualified Intellectual Disabilities Professional (QIDP). Revisions are called for in situations such as completion of objectives identified in the IPP or the loss of skills gained.
Reassessment and/or Discharge
At least annually, the comprehensive functional assessment of the client must be reviewed by the IDT for relevancy and updates, and the IPP must be revised as appropriate. If a client is to be discharged, the facility must develop a summary of the client's developmental, behavioral, social, health and nutritional status, as well as a post-discharge plan of care that will assist the client in adjusting to the new living environment.
Category 2: Client Protections
The federal client protection standards identify the rights of all clients, such as freedom from unnecessary drugs and physical restraints and the provision of active treatment to prevent their use, freedom from abuse, and the provision of opportunities to participate in social, religious, and community activities, to name a few. Client protection standards also call for systems that protect a client's personal funds and the client's access to personal funds. In addition, the standards lay the groundwork for appropriate communications with clients, parents, and guardians. Staff treatment of clients and necessary measures to prevent mistreatment, neglect or abuse also are discussed in the regulations.
Category 3: Client Behavior
Client behavior standards underscore the importance of facility practices that maximize client choice and autonomy. Facility policies address the degree to which client choice will be incorporated in daily decision-making. To the extent possible, clients participate in the formulation of these policies.
In managing inappropriate client behaviors, facilities emphasize client safety, welfare, and the protection of human rights. In directing client behavior, ICFs/IID primarily focus on positive behavioral management programs that reward appropriate behavior, thereby eliminating undesirable behaviors.
Use of more intrusive techniques is regulated under federal law and must be part of the client's IPP in order to be applied. Such methods are never used for disciplinary purposes or for the convenience of staff.
Category 4: Health Care Services
The approach to health care services in ICFs/IID relies on the interdisciplinary team approach to meeting the client's needs and underscores preventive care.
Physician services must be accessible round-the-clock. Together with licensed nursing staff, physicians are required to develop a medical care plan of treatment for only those clients who require 24-hour nursing care. This medical plan becomes a component of the individual program plan.
Annual physical examinations to evaluate vision and hearing and to ensure proper immunization and screening for tuberculosis is provided for each client. Staff, as well as clients, are trained in appropriate health and hygiene methods, in order to control communicable diseases. Comprehensive dental services, pharmacy services, and systems for monitoring drug administration also must be arranged by the facility.
ICF/ID provides Active Treatment, a continuous, aggressive, and consistent implementation of a program of specialized and generic training, treatment, and health or related services, directed toward helping the enrollee function with as much self-determination and independence as possible.
Federal rules provide for a wide scope of required services and facility requirements for administering services. All services including health care services and nutrition are part of Active Treatment, which is based on an evaluation and individualized program plan (IPP) by an interdisciplinary team These four primary conditions of participation -- active treatment, client protection, client behavior, and health care services -- reflect the survey processes' new resident focus and emphasis on outcomes. Overall, the goal is to encourage interaction with and assessment of individuals who reside in ICFs/IID, rather than a heavy reliance on reviewing written records.
Federal standards require that active treatment programs are established and monitored by a Qualified Intellectual Disabilities Professional (QIDP). The QIDP is a professionally trained individual who is responsible for overseeing implementation of the IPP. The QIDP must meet the qualifications outlined in ICF/IID conditions of participation.
Other staffing requirements state that direct care staff must be on duty and awake round-the-clock to take appropriate action in case of emergency. Support staff also must be provided to assure that direct care staff are not distracted from their duties.
Direct care staffing requirements are based on client age and level of disability. Direct care staffing is defined as present on-duty staff calculated over all shifts in a 24-hour period for each defined residential living unit. These staff must be provided in the following ratios:
- • For each defined residential unit serving children under the age of 12, severely and profoundly intellectual disabled clients, clients with severe physical disabilities, clients who are aggressive and pose security risks, or clients who are severely hyperactive or demonstrate psychotic-like behavior, the staff to client ratio is 1 to 3.2
- • For units serving moderately intellectual disabled clients, the staff to client ratio is 1 to 4.
- • For units serving clients who are mildly intellectual disabled, the staff to client ratio is 1 to 6.4.
ICFs/IID provide employee training to ensure that staff can perform their duties effectively. For employees who work with clients, this training focuses on skills to help them meet clients' developmental, behavior, and health needs. Staff also are required to demonstrate the essential skills to implement individual program plans for the clients for whom they are responsible.
-ICFs/IID Medicaid Expenditures-
ICF/IID services represent a significant segment of the long-term care spectrum. Because adults with developmental disabilities require lifelong support, these adults are highly dependent on public programs to finance their long-term care needs. According to the U.S. General Accounting Office, individuals with developmental disabilities "receive more than $13 billion annually in public funding for long term care -- second only to the elderly."
Medicaid is the primary payer of ICF/IID services, although some clients are considered disabled children and may access their parents' Medicare and Social Security.
Since the ICF/IID program began, more than over 50 years ago, many individuals have been able to live in home-like, less restrictive settings. Individuals receive long-term care in an environment where individual potential is maximized and personal needs are thoroughly assessed and fulfilled. Professional staff and government oversight work together to assure that the needs of individuals living in ICFs/IID are the driving force behind services provided.