Social Assistance and Community Services

How a typical employer in social assistance and community services operates

A typical employer in this industry gathers people who need care or support into a place, at a scheduled time, under a public payer's rules, with a workforce of direct support professionals and drivers, volunteers drawn largely from adults over sixty-five, and counterparties that include State Medicaid, aging, disability, vocational-rehabilitation and child-welfare agencies, hospitals and physicians, schools, courts, benefits offices, landlords, manufacturers, grocers and the federal Departments of Housing and Urban Development, Agriculture and Health and Human Services. Every one of its functions is congregate, payer-dependent or both, and each is described below in the operational terms an order can reach: what happens, where, with whom and on what inputs.

The four segments

The industry has four operating segments that share a workforce, a payer structure and a population served. The first is aging services: adult day care and adult day health centers (medical and social models), senior centers and congregate-meal sites, and the home-delivered-meal programs that share their kitchens and drivers. The second is developmental-disability services: day habilitation, prevocational and community habilitation programs, group homes and other community residences, and intermediate care facilities for individuals with intellectual disabilities (ICF/IIDs). The third is vocational rehabilitation and community rehabilitation programs, including sheltered work under section 14(c) certificates and the AbilityOne program, supported employment and job coaching. The fourth is family, youth and community services: child-welfare and foster-care agencies, counseling and case-management agencies, food banks, pantries and soup kitchens, homeless shelters and rapid re-housing programs, and the transportation fleets that serve all four.¹

The eleven functions

AD. Adult day and senior-center programs

The adult day function operates a licensed center that receives participants by van or family drop-off each weekday morning, serves a congregate breakfast and lunch, provides nursing oversight, medication administration, therapy, personal care and structured group activities in shared rooms, and returns participants home in the afternoon. It is billed to the State Medicaid program by the hour or day of attendance, to the Department of Veterans Affairs under community adult day health care contracts, to area agencies on aging under the Older Americans Act, and to families privately; no attendance means no unit and no revenue. The senior-center function operates a municipal or nonprofit building open to older adults for congregate meals reimbursed per meal under Title III-C of the Older Americans Act, classes, recreation, benefits counseling and transportation. Both functions exist to gather older adults, the class of persons every stay-at-home order addressed first and confined longest, into one room; an order closing "places of assembly such as adult day care centers" or providing that "all facilities that conduct adult day services or other senior citizen centers are hereby closed" terminates the function in terms.²

DD. Developmental-disability day and residential programs

The day-habilitation function transports adults with intellectual and developmental disabilities to a certified site each weekday for skill-building, prevocational and community activities in groups, billed to the State's section 1915(c) waiver in fifteen-minute or daily units under a service definition that requires congregate, site-based delivery unless the waiver is amended. The residential function operates group homes and ICF/IIDs in which four to sixteen residents live with round-the-clock direct support staff, receive visitors, dine communally, attend day programs off-site and are transported to medical appointments; it is paid by waiver and ICF per diems that assume a staffing ratio, an occupancy and a program schedule. The federal conditions of participation for ICF/IIDs, the State licensing rules for community residences and the waiver's Appendix K amendments fix how each of those things is done.³

VR. Vocational rehabilitation and sheltered work

The vocational rehabilitation function assesses, trains, places and coaches people with disabilities under fee-for-service and milestone contracts with the State vocational rehabilitation agency, most of the work done in person at the program's site, at the customer's workplace and in group classes. The sheltered-work function fills production contracts, assembly, packaging, kitting, mailing and grounds work, for manufacturers, distributors and federal agencies under section 14(c) certificates and the AbilityOne program; its customers are the manufacturing plants and federal facilities whose orders on non-essential production are catalogued on the Manufacturing page and whose workplace-access and contractor-entry rules are set out in the third-quarter 2021 inventory below; when the customer's plant is closed or its purchasing suspended, the contract has no work.⁴

FS. Family, youth and counseling services

The family-services function conducts child-protective and foster-care casework, home visits, supervised visitation, court appearances in dependency and guardianship proceedings, counseling sessions, benefits enrollment at Social Security and county offices, after-school and youth programs, and Head Start and early-intervention programs co-located with schools. Its work is performed in families' homes, in courtrooms, in benefits offices, in schools and in group rooms, each of which was closed, converted to remote operation or conditioned by order.⁵

FD. Food banks, meals and shelters

The food-bank function receives donated and USDA commodity food at a warehouse, sorts and repacks it with volunteers, and distributes it through pantries, mobile distributions and agency partners; the meal function serves congregate meals at soup kitchens and senior sites and delivers meals to homes; the shelter function houses people in congregate dormitories, serves meals in dining rooms, and provides case management, rapid re-housing and homelessness-prevention assistance under HUD's Emergency Solutions Grants and Continuum of Care rules, State and local shelter contracts and FEMA Public Assistance. Every one of those operations is a gathering; every one depends on a volunteer corps; and the federal rules under which the shelter function is paid were rewritten by HUD on March 31, 2020 and again on September 1, 2020 and July 19, 2021.⁶

TR. Participant transportation

The transportation function operates vans and small buses, many with lifts, that collect participants at home each morning, deliver them to the day program, the senior center, the workshop or the medical appointment, and return them; it is billed as a waiver or Older Americans Act unit or as a paratransit contract, and its capacity is fixed by the number of seats an order allows to be filled and by the airborne-transmission and screening controls that govern every conveyance. From February 1, 2021 the Centers for Disease Control and Prevention's conveyance order and the Transportation Security Administration's directives governed every vehicle in which a member of the public was carried.⁷

PY. Payers and licensing

The payer function bills State Medicaid agencies, managed-care and managed long-term-services-and-supports plans, area agencies on aging, State vocational rehabilitation and child-welfare agencies and HUD grantees under service definitions, unit rates, documentation rules and licensing standards that each State's aging, disability, health and human-services agencies administer. When CMS approved a State's Appendix K amendment, the service definitions changed: day habilitation became billable in a participant's home, retainer payments replaced attendance billing, assessments went remote, and visitors were barred from provider-owned settings, each by the terms of a federally approved amendment with force as a condition of federal financial participation.⁸

HR. Hiring, screening, training and credentialing

The hiring function recruits direct support professionals, aides, drivers, counselors and shelter monitors; runs background checks, fingerprinting and drug tests; trains and certifies in medication administration, first aid and abuse prevention; and, for drivers of larger vehicles, obtains and renews commercial driver's licenses through motor-vehicle offices. Each of those steps depends on an office, an examination site or a training room that the orders closed or conditioned, and in the third quarter of 2021 the vaccination and testing mandates of seventeen jurisdictions changed whom the employer could hire and retain.⁹

OP. Office, administration and telework

The office function conducts intake, eligibility, service planning, billing, grant administration and the Homeless Management Information System reporting on which HUD funds depend, largely in person before March 2020. Under the telework mandates and the Appendix K and HUD waivers, intake and case management moved to telephone and video, re-evaluations were rescheduled, and reporting deadlines were changed by the funders.¹⁰

WF. Workforce availability

The workforce is direct support professionals and personal care aides with high turnover and Medicaid-constrained wages, drivers, licensed social workers and counselors, job coaches and shelter monitors, and a volunteer corps concentrated among adults sixty-five and older. It commutes by car and by transit; its children were in schools and child-care programs closed for the spring of 2020 and, in much of the country, remote or hybrid for the 2020-21 year; it was subject to the leave mandates of the Families First Coronavirus Response Act from April 1 to December 31, 2020, to quarantine and isolation orders on exposed persons, to the airborne-transmission controls imposed on every transit commute and, from July to September 2021, to the vaccination and testing mandates naming congregate-care and adult day workers.¹¹

CB. The people served and their funders

The people served are older adults, adults with intellectual and developmental disabilities, families in the child-welfare system, people experiencing homelessness or food insecurity, and the public and private funders who pay for their services. The first two groups were the subject of the stay-at-home orders for persons over sixty-five and the medically fragile, the visitation bans on congregate settings and the school and day-program closures; the funders operated under the same emergency orders, waivers and grant conditions as the providers.¹²

The revenue lines, inputs and seasonality

Revenue

Revenue is public and unit-based in every segment: Medicaid waiver and State-plan units for adult day, day habilitation, residential and transportation services; ICF per diems; Older Americans Act per-meal and per-unit reimbursement; Department of Veterans Affairs adult day contracts; vocational rehabilitation fee-for-service and milestone payments; 14(c) production contracts and AbilityOne revenue; Title IV-E and IV-B, TANF, CSBG and Medicaid behavioral-health billing; HUD ESG and CoC, CDBG, FEMA Public Assistance and State and local shelter contracts; and private philanthropy, United Way allocations and donated food. Because the Medicaid and Older Americans Act units are earned only by attendance or delivery, an order closing the site or capping its occupancy terminates the revenue of the function on the day it takes effect.

Inputs

The industry's inputs are personal protective equipment, cleaning supplies and testing (subject to the federal allocation orders and the scarce-materials designation of 2020); food (donated retail and restaurant surplus fell when retail and dining were closed, and USDA commodity supply rose under the Farmers to Families Food Box program of May 2020 to May 2021); vehicles and plexiglass; and the software and telephony of remote service delivery.¹³

Seasonality and geography

Congregate meals and adult day programs run year-round with winter peaks; food banks peak in the summer and the holidays; cold-weather shelters open from November to March; vocational rehabilitation and youth services follow the school year; and contract cycles turn on July 1 and October 1 fiscal years. The industry is present in every county in the United States, because the people it serves are, and its regulatory regime is set State by State by the aging, disability and human-services agencies of each State under federal waiver and grant rules that apply in all fifty-one jurisdictions.

The counterparty map

Each counterparty class was reached by orders that limited commerce, travel or group meetings in terms, and the layers section below inventories them. The table states the class, the orders that reached it by category, and the layer in which they appear.