THE EFFECT OF CMS' FINAL RULE AND KANCARE UPON DAY SERVICES
Since 1968 COF has provided the standard types of day services options commonly offered across the nation by providers of social services to people with intellectual and/or developmental disabilities. COF owns two large facilities, one located in Burlington and one in Ottawa, from which day services are delivered. Day services are typically inclusive of what are commonly referred to as sheltered workshops. Additionally, in Osage City, COF shares space with the Senior Center from which day services are provided within a fully integrated setting.
Historically across the nation, most day services for people who are intellectually and/or developmentally disabled have been provided in segregated settings existing primarily, if not exclusively, for the use of a specific category of people who are disabled. The only non-disabled people who go to these settings (buildings) are employees who are paid to provide services to the persons with disabilities who attend.
THE FINAL RULE
In early 2014 the Center for Medicaid and Medicare Services (CMS) announced what it refers to as its Final Rule. CMS’ Final Rule pertains to a category of Medicaid Funding known as Home and Community Based Services (HCBS). The fundamental theme or area of concern underlying CMS’ Final Rule is the segregation of people who are disabled from those who are non-disabled. In the mid-1960’s important Civil Rights legislation was passed to protect against racial segregation. Before that legislation was passed, discrimination due a person’s race was commonly practiced in various ways in parts of the United States. Though it happens in much less conspicuous ways, CMS passed its Final Rule to ensure that federal funds used to provide HCBS-funded supports and services to people with disabilities were not being used in such a manner as to encourage segregation of this population and to ensure recipients of those HCBS-funded supports and services were not inadvertently being discriminated against due to age or disability.
Segregation Issues Addressed
Historically over the past forty to fifty years, the actual building sites from which day services/sheltered workshops have provided supports and services to people with disabilities have had the effect of segregating those individuals who are disabled from those who are not disabled. Unlike racial discrimination, though, no malicious intent can be ascribed. This has simply been a byproduct of the service delivery system that evolved and the way in which those services were funded.
The buildings in which day services are provided are “settings” that have the effect of segregating or isolating people who have intellectual and/or developmental disabilities from people who are not disabled. CMS’s Final Rule requires that compliance authorities assess each and every “setting” in which HCBS-funded services are provided to determine whether or not those “settings” have the effect of isolating people who are disabled from people who are not disabled.
Medicaid is a partnership between the federal government and each of the fifty individual states. Each state has to ensure that HCBS-funded services are in compliance with CMS’ Final Rule as soon as possible but not later than 5 years from the inception of CMS’ Final Rule (2014). If compliance is not achieved loss of crucial HCBS funding to states and/or to providers of HCBS-funded services is at stake.
The ramifications of CMS’ Final Rule are so profound that it is simply not possible to predict what it all means to organizations providing services and to those who receive those supports and services. The delivery of services cannot have the effect of isolating (segregating) people who are disabled from people who are not disabled. The difficulty confronting the many long-established organizations that have been part of this current system is to ensure that the supports and services continue without the organizations knowing exactly how those services will need to be provided in order to meet the Final Rule standards. In jeopardy is the long established practice of providing valuable day services in buildings (settings) that have the effect of isolating people who are disabled from those who are not disabled.
Day Services/Sheltered Workshops
The primary distinction between a sheltered workshop and a day service program might be that day service programs, in general, are more focused on providing non-wage earning types of activities within the sheltered workshop setting. Day services programs, though, often have a component of employment services that provide help for program participants to find employment opportunities outside of the sheltered workshop setting. Terms such as day services, sheltered workshops and employment services are often used interchangeably. Nonetheless, as with sheltered workshop settings, CMS’ Final Rule will not allow for day service “settings” (buildings) to be used that have the effect of isolating (segregating) people with intellectual/developmental disabilities from people who are not disabled. It is assumed that no disabling condition is so significant that a person is entirely unemployable. This assumption puts added impetus on organizations that have historically provided the standard types of day services within the sheltered workshop setting to find, if at all possible, some form of employment, even if only a minimal part time job, that meets CMS’ definitions (see below) of integrated/competitive employment for each participant regardless of the level of their disability.
The Demise of the Sheltered Workshop Model
COF and many other organizations similar to it across the nation were originally founded some forty to fifty years ago by parents of people with intellectual/developmental disabilities. The terms sheltered workshop and day service programs are often comingled or used interchangeably. Original founders, as parents, were looking for a place where their loved ones could go every day instead of being confined to their homes. The intent of sheltered workshops was to provide at least some minimal type of employment opportunity. Usually that employment came from manufacturing plants that could subcontract work to the sheltered workshop. This benefitted the manufacturer because it was usually the most menial work, and it could be done more cost effectively in a sheltered workshop setting by paying subminimum wages as allowed by federal law. This subminimum rate is based on the premise that workers with I/DD cannot always produce at the productivity level required of a non-disabled worker in a manufacturing setting.
Finding enough work to keep people occupied in a sheltered workshop setting became more and more difficult over time and across the nation as more and more manufacturing jobs were outsourced to other countries where cheaper labor could be found. Additionally, advances in automation have reduced or entirely eliminated many manufacturing jobs. While CMS’ Final Rule does not technically ban sheltered workshops, it will ultimately have that effect.
The fundament of the CMS’ Final Rule calls for assessing whether or not the “setting” (building) where services are provided has the effect of isolating (segregating) people with disabilities from people without disabilities. Sheltered workshops by definition explicitly have the effect of isolating people who are intellectually/developmentally disabled from people who are not disabled. A person who is not disabled has no reason or need to go to a “sheltered” environment for work.
Integrated employment and competitive employment have been formally defined within the CMS Final Rule in such a manner as to ensure the gradual demise of sheltered workshops. Sheltered workshops are not settings at which integrated employment or competitive employment can be provided.
Integrated employment is formally defined as:
“with respect to employment outcome, a setting typically found in the community in which applicants or eligible persons interact with non-disabled individuals, other than non-disabled individuals who are providing services to those applicants or eligible persons, to the same extent that non-disabled individuals in comparable positions interact with other persons.”
Competitive employment is formally defined as:
“work (1) in the competitive labor market that is performed on a full-time or part-time basis in an integrated setting: and (2) for which a person is compensated at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by persons who are not disabled.”
Neither competitive employment nor integrated employment occurs within the sheltered workshop setting. The long established sheltered workshop model is nearing its end.
Additional powerful converging forces are pushing towards the demise of sheltered workshops. For example, the Workforce Innovation and Opportunities Act (WIOA) was signed into law on July 22, 2014 to take effect on July 1st, 2015.
CMS’ Final Rule subjects providers of services to what it calls “heightened scrutiny” if the provider owns, operates, or controls a day center/sheltered workshop. Additional heightened scrutiny occurs if that same provider also owns, operates, or controls the housing in which its day service attendees live. The concern highlights a potential conflict between the service provider and the wishes of the person receiving those services. A single service provider should not have too much control over the lives of the individuals who access those services. Of additional concern is that service providers or organizations are being run for the staffing conveniences of the organization rather than for the wishes and desires of the individual who receives those services. The individual should be in control of his/her life to the greatest extent possible.
The federal Department of Justice (DOJ) has caused sheltered workshops to be closed. The State of Rhode Island entered into a consent decree, for example, with the DOJ in which it agreed to gradually close its sheltered workshops. Court document found here
The State of Oregon has recently taken similar steps for similar reasons. Disabilityscoop article
In North Dakota, compliance authorities issued the first of what promises to be many, many “heightened scrutiny” responses. An organization providing services in North Dakota failed to meet the standards of CMS’ Final Rule. CMS stated, “the Day Program setting does not meet the characteristics of home and community based (HCBS funded) services because the majority of individuals receive most of their services at the facility-based program and not integrated into their greater community.” The State of North Dakota has been directed by CMS to “either identify more appropriate services for the participants, or make appropriate changes to the services to bring into compliance (with CMS’ Final Rule).” ancor article of cms issues first heightened scrutiny response of North Dakota
The body of articles and documents pointing to these impending changes is exhaustive. It is no longer a question of “if” changes will occur. It is now only a matter of how soon these changes will occur. The following link provides additional articles and documents pertaining to these changes:
Many organizations like COF own, operate or control both day centers and residential settings. Typically, they run extensive transportation routes that are convenient to the operational needs of the organizations’ staffing schedules for its day and residential services. From the perspective of CMS’ Final Rule, this provision of transportation on a scheduled basis is no longer suitable because it inadvertently disregards the needs and preferences of the individual receiving the services in favor of the staff scheduling needs of the organization. HCBS funding is intended to benefit the individual to the greatest extent possible, regardless of the needs of the organization. One way of measuring this is by the amount of latitude and flexibility the individual is allowed in his/her daily routine. The underlying fundament of CMS’ Final Rule comes down to integration and inclusion in the community in which the service recipient lives while accessing the same services and same places in the same flexible ways as do non-disabled people.
In short, many long established practices regarding how and when day services/sheltered workshops are provided must change.
COF’S RESPONSE TO THE FINAL RULE
Now that we understand why COF is changing the way it provides supports and services regarding its day, sheltered workshop and employment services, let’s discuss what changes COF has made (as of 12-22-15) and is in the process of making.
Integrated Day Services: with regards to CMS’ Final Rule, the easiest way to think about it is to simply think about integration. CMS’ Final Rule does not try to take away essential HCBS-funded services. Services are not one and the same as the buildings in which those services have been provided for many years. That’s what’s so hard for so many people to understand. Services will and must continue. They simply cannot continue to be provided in isolation in settings (buildings) that are segregated from non-disabled citizens who are paid to provide services. That’s the task at hand for organizations like COF. COF is blessed to be able to provide services in communities that are very open to and accepting of people with I/DD. Here are some of the things that we are doing to ensure that we are providing fully integrated day services.
For many years, service recipients living in Osage City had been transported to Burlington for day services, an approximate 85-mile round trip, five days a week. Now, however, COF in conjunction with Osage City’s Senior Citizens Center provides day services out of that senior center building in Osage rather than requiring individuals be bussed to Burlington. In addition to no longer being bussed in congregate fashion on an arduously long trip each day, people with I/DD using COF’s day services in Osage City are no longer receiving those services in a setting (building) in isolation from people who are not disabled. COF’s day services in Osage City are provided in a fully integrated location in the heart of the town; individuals with disabilities are interacting daily with persons without disabilities in natural way, and COF now provides fully integrated services as is required by CMS’ Final Rule.
In Ottawa, COF is in the process of opening a new Thrift Store at the former Goodwill store location. It will be called Thriftopia. It will be an open and welcoming environment where citizens can shop and mingle and visit. COF will blend some aspects of its day services for some of the people it serves in Ottawa into this naturally integrated environment. In addition to the steady flow of customers and visitors into the Thrift Store which will significantly enhance integration, the location of this Thrift Store is in a mix of many established businesses on Ottawa’s south side where persons receiving services can easily access numerous restaurants and stores. Another advantage of this location is that it can serve as an easy access base to the many jobs that are available on Ottawa’s south side. Additionally, there will be competitive and integrated employment opportunities for some of the people who use COF’s day and employment services within the store itself. Most importantly, as COF has been able to do in Osage City, day services in Ottawa will be provided in a fully integrated location in the heart of the town; individuals with disabilities will be interacting daily with persons without disabilities in a natural way, and COF will provide fully integrated services as is required by CMS’ Final Rule. The target date for opening Thriftopia is April or May of 2016. Thriftopia will be established as a not-for-profit limited liability company (LLC) to facilitate the necessary degrees of separation suggested by the implications of CMS’ Final Rule.
In Burlington, COF is in the process of remodeling its day center. This remodeling should be completed by the end of February 2016. With the twenty to twenty-five people from Osage City no longer traveling to this site there will be more space in the Burlington building. By remodeling the south end of the building, that space can now accommodate the forty to fifty people who routinely use COF’s Burlington-based day services. As has been done with COF’s Ottawa day facility, the middle part of the building (the “sheltered workshop” part of building) will be used in conjunction with Integrated Employment Enterprises (see the section below about IEE) for the creation of jobs that meet the formal definitions of competitive and integrated employment as required by CMS’ Final Rule. Remodeling the Burlington’s day center will create a better and more welcoming environment. Yet that, in and of itself, will not move us as far along toward the integration required by CMS’ Final Rule as we have been able to achieve in Osage City and Ottawa. In as much as citizens of Burlington have always been particularly supportive of and welcoming of people with I/DD, COF intends to encourage citizens of Burlington to consider this remodeled space as a place where they can come by and visit any time, a place for use by the citizens of Burlington as a community center or to hold events. In so doing, this will enhance opportunities for integration and inclusion into the Burlington community.
- Integrated Medical Services are no longer a component of day services
Historically, organizations like COF provided nursing services. These services were typically based out of the organization’s day centers, as were COF’s nursing services. Many people with intellectual/developmental disabilities take prescribed medications, and organizations such as COF are required by regulation to have a registered nurse on staff. Staff members who are not nurses, though, may pass individuals’ medications under the auspices and with training from a registered nurse. Many people with intellectual/developmental disabilities are not fully capable of taking their medications without assistance or supervision from staff. Technically that is the primary reason organizations like COF have had nurses on staff. Over time, though, “nursing departments” similar to mini-medical clinics evolved at day centers. COF still has a registered nurse on staff but the nurse no longer provides the wide array of medical services that has typically evolved at day centers. CMS’ Final Rule explicitly requires that people who receive HCBS-funded services from providers like COF should not receive those services in settings (buildings) in isolation (segregated) from where other non-disabled citizens go to receive those same services. Day service recipients need to receive medically-related services at doctors’ offices, clinics, emergency rooms or hospitals as do non-disabled people. This use of the community’s medical services is an example of what is meant by the concepts of integration and inclusion. COF and other organizations like it are not licensed to be providers of medical services; rather, they are licensed to be providers of social services. COF no longer provides designated nursing spaces out of its day centers in Ottawa and Burlington like it did for many years. COF continues to keep a nurse on staff to oversee the daily delivery of medications multiple times at multiple locations to well over a hundred people. Additionally, COF employs a nurse to provide medically-related trainings to educate and empower staff and participants in becoming more self-reliant in knowing why, when, where and how to access medical services that are based in the community. Users of COF’s day services are now helped to receive all of their medical services at doctors’ offices and clinics in the same way as everybody else does. This is another example of the integration that CMS’ Final Rule is requiring.
- Fostering volunteerism as a means of facilitating integration & inclusion through day services
COF strongly encourages volunteerism among its day service users who do not work full time. COF recently received a volunteer recognition award from ECKAN for its role in food distribution to people in need. COF also played a strong volunteer role in Ottawa’s 150th anniversary celebration by helping the local Arvest Bank serve hot dogs and picnic-type foods and beverages to the entire Ottawa community who turned out to enjoy the activities. The community of Ottawa hosts an annual “Ol’ Marais River Run” car show. Persons receiving services volunteer to help man the road barriers along the cars’ driving routes. There are many other examples of COF fostering the persons who receive services to be volunteers within the three counties which COF services. Volunteerism provides recipients of COF’s services who are accustomed to being in the “receiving” mode to instead become “givers.” In so doing, integration and inclusion occur naturally along with enhanced self-esteem and pride in accomplishments. As matter of fact, if you are citizen of Burlington; Osage City; or Ottawa, seeing people who receive services from COF volunteering in your community is a common, routine sight. You come to expect it, to take it for granted. That’s exactly how it should be!
- Fostering Civic Club/Community Organization Memberships as means of facilitating integration & inclusion through day services
COF works diligently to match those who receive day services to civic clubs and community organizations that might be a good fit for an individual. This matching process entails a dedicated staff person researching and reaching out to the wide array of great civic organizations that prosper in every community to gain a good understanding of the membership and of what the organization’s mission is. Then this information has to be adequately conveyed to individuals who might be interested in joining. Then the staff person will help to support the prospective new member through the transition period of learning what it entails to be an active member of the community service organization. As with any other citizen the right match with the right civic organization is an individualized choice process.
- Exploration of the Arts as a means of fostering integration & inclusion through day services
COF has hired a professional artist on staff to work with individuals to develop their artistic talents. The art the individuals produce is taken to community fairs, festivals and events where they showcase and sell their products. This provides the individuals an opportunity to receive their own money for the products they have made, and as importantly, it provides a great opportunity for integration and inclusion as well as pride of accomplishments Steven Terrys Day at Hartford Harvest Days Many of the art classes provided by COF’s staff are offered in integrated settings where non-disabled citizens can join in. Locations of classes include the Library in Burlington; the Senior Center in Ottawa; and the Senior Center in Osage City. Additionally, individuals will be developing their culinary arts and selling these foods at community festivals, fairs and events.
- Staggered Staffing Schedules ensures enhanced opportunities for employment and for integration
As of __________, COF’s three day services programs will operate on staggered schedules instead of bussing everybody to and from the day centers at the same time for the convenience of the organization’s operational staffing needs. Varied shift schedules offer more latitude and flexibility to individuals receiving services. For example, an individual residing in one of COF’s 24 hours shift homes no longer must board the same bus at the same time as their seven other housemates in order to go to the same place, and then return home together on the same bus at the same time. Flexibility of scheduling allows more choice opportunities to those receiving services. This is an important concept in CMS’ Final Rule because the Final Rule wants to ensure that each individual has as much control of their own time and scheduling as possible, just like most of us do.
EMPLOYMENT = the surest and most natural way to achieve integration and inclusion!!!
COF is very proud of the remarkable strides it has made in helping the people who receives services have opportunities for competitive and integrated employment. COF whole heartedly believes that it is essential to help individuals who are reliant on government subsidies including Medicaid to become less reliant on these subsidies. Medicaid and other such programs are unsustainable at their present rate of growth over the long haul. The best way to decrease the pressure on the over-stressed government subsidy programs such as Medicaid is to facilitate opportunities for employment. This is the hallmark of COF. So much so in fact, that COF is in the process of transitioning from being a provider of standardized services exclusively to people with I/DD to being a provider of diversified employment and social services to anybody who is in need of employment and/or social services and who wants to decrease their reliance . . . in varying degrees. . . upon government subsidies. To this end, COF has developed the tax-weight-loss™ concept (refer back to opening comprehensive document). Our goal is to measurably decrease the reliance upon government by people who use our services. You can monitor the plausibility of our theory and our progress monthly by referring to this link.
- COF is proud to be a Department of Vocational Rehabilitation Services Vendor
In order to enhance COF’s employment services, COF is vendor of (provider of) services funded by the Department of Vocational Rehabilitation Services. In so doing COF no longer limits itself to facilitating employment opportunities to only the population of people with I/DD it has been privileged to provide services for since 1968. Additionally, COF no longer limits itself to facilitating employment services in our former three county catchment area of Coffey, Osage and Franklin counties (COF). We now offer these services to anybody with any type of disability in the following additional counties: Josh needs to list and he needs to update the list in real time as we expand. Check back with us regularly to find out if we have expanded these services to your area. We intend to expand!
- COF is proud to be an official Certified Employment Network
To further enhance and expand our employment services COF has become a certified Employment Network (ticket-to-work).
- IEE: Integrated Employment Enterprises
Finding competitive and integrated work opportunities is indeed difficult, and it is especially true in rural areas. As helpful as good, solid employment services such as COF provides are, more is needed than the standard types of employment services.
- IEE is an actual, legally-formed business. IEE opened at the beginning of 2015. Unlike COF, IEE is not a provider of social services. Like COF, it is a not-for-profit tax exempt 501(c)(3) entity. It is a special type of 501(c)(3). It is a fully integrated supporting organization (FISO) to COF which is the supported organization. Other organizations like COF can opt to become supported organizations with IEE. IEE is what is known as a Type III supporting organization which means that it has to satisfy certain integral activities tests. To meet these requirements substantially, all of the supporting organization’s (IEE’s) activities must be “direct furtherance” activities that are conducted by the supporting organization (IEE) itself rather than by the supported organization (COF).
- Traditional employment services: IEE’s “direct furtherance activities” increase integrated and competitive employment opportunities by providing those opportunities as an actual, legitimate employer. These furthering, supporting activities are essential because of the inherent difficulties found in standard employment services provided by COF and other organizations like it. Typically, organizations like COF have dedicated staff going door-to-door to places such as McDonald’s; Wendy’s; Burger King; hotels and motels to help individuals find minimal, part-time employment. COF devotes a great deal of time and energy to this long-established model for finding employment for people with disabilities. However, this model is not adequate to find enough work in sufficient volumes to help more than 100 people with disabilities earn enough money to substantively decrease their reliance on government subsidies. This is especially true in rural areas. Also, current funding methodologies are far too inadequate for this to ever be a viable model for finding and accessing high volumes of employment. COF will continue to push this model very hard, but, in and of itself, it’s just not enough. Further exacerbating the difficulties with this traditional employment-finding model is the fact that the sheltered workshop model is in demise because of CMS’ Final Rule. Further exacerbating the difficulties with this model is the fact that the sheltered workshop model is in demise because of CMS’ Final Rule.
- Provider of diversified employment and social services: As we stated previously, “COF whole heartedly believes that it is essential to help individuals who are reliant on government subsidies including Medicaid to become less reliant on these subsidies. Medicaid and other such programs are unsustainable at their present rate of growth over the long haul. The best way to decrease the pressure on the over-stressed government subsidy programs such as Medicaid is to facilitate opportunities for employment. This is the hallmark of COF. So much so in fact, COF is in the process of transitioning from being a provider of standardized services exclusively to people with I/DD to being a provider of diversified employment and social services to anybody who is in need of employment and/or social services and who wants to decrease their reliance . . . in varying degrees. . . upon government subsidies.” One of the surest ways to ensure that there are employment opportunities is to create an actual business model that generates employment opportunities. That’s exactly what we have done with IEE.
- Both non-disabled and disabled employees working for IEE: IEE turned one year old at the beginning of 2016. It has approximately 55 employees. Approximately half of those employees are “non-disabled” people working side-by-side at the same wages and benefits as their disabled colleagues. And, these non-disabled workers are not staff paid to provide supports and services to their disabled co-workers. For a brand new company in a rural area to provide that much competitive and integrated employment for so many people in its first year is an impressive feat. It wasn’t easy. IEE is not meant to be a cure-all for all of the employment needs of people with disabilities. It is a piece of a complex puzzle. We believe that it is model with broad applications that other organizations like COF can also utilize. We very much hope to see other organizations like COF become supported organizations of IEE! http://www.iee-inc.org/
- Snack Master& Stan’s Cleaning
Snack Master is a vending company. Stan’s Cleaning is a floor cleaning and contract cleaning company. Each company is a not-for-profit limited liability company. COF has created close ties with both companies, as with IEE, for the specific purpose of ensuring access to substantive competitive and integrated employment opportunities for people with disabilities.
In combination with CMS’ Final Rule, KanCare’s impact on the way day services are provided to people with intellectual &/or developmental disabilities will be significant. COF is committed to navigating these changes as gracefully as it possibly can with due regard for the converging forces that are causing these changes. But, most importantly, COF is trying to do this with all due consideration to the people it is privileged to serve and their families. It is sometimes a delicate balance. It is always complicated to explain.
All of COF’s concerted efforts to help people who are reliant upon government subsidies, especially Medicaid, are particularly important with regard to Kansas’ KanCare model. This is because the basis of this model is to contain the ever spiraling costs of Medicaid. Decreasing people’s reliance upon government subsidies, including Medicaid, by increasing their earned income through employment is one of the surest ways to contain the escalating costs of Medicaid.
Another way to contain those costs is for providers of social services to find more cost-effective ways to deliver Medicaid funded services. COF has demonstrated its commitment to more cost-effective methods of service delivery by becoming one of the largest service providers of the Working Healthy/WORK/ILC model. Although this option is applicable to anyone who has any type of a disability, it can also be applied to some higher functioning people with I/DD who have historically relied upon the more costly Medicaid/HCBS-funded services which are the primary source of funding for organizations like COF.
CMS’ Final Rule + Kancare = CHANGE. As we have explained, CMS’ Final Rule and KanCare are the two primary converging forces of change confronting the field of intellectual and developmental disabilities. These are just two among many other converging forces that are causing change in the way all types of government-funded social and medical services are provided. Refusing to change is not a viable option. However, the rate of change for any organization that provides these services may vary. Some organizations are taking a “wait-and-see approach” in which they are prolonging their operations and service-delivery status quo as long as they can until imposed changes are finally enforced. Other organizations such as COF are proceeding with changes in varying ways at varying rates of speed. COF has chosen to embrace these changes instead of trying to resist them. In so doing, COF is making changes at a fairly progressive rate of speed.
Many if not most people do not like change. At COF we understand this. Continually trying to explain the complexity of changes and the reasons for changes we are being confronted with is a daunting task.
COF strongly encourages volunteerism among its day service users who do not work full time. COF recently received a volunteer recognition award from ECKAN (scan internal link to article / photos) for its role in food distribution to people in need. COF also played a strong volunteer role in Ottawa’s 150th anniversary celebration by helping the local Arvest Bank serve hot dogs and picnic-type foods and beverages to the entire Ottawa community who turned out to enjoy the activities. The community of Ottawa hosts an annual “Ol’ Marais River Run” car show. Persons receiving services volunteer to help man the road barriers along the cars’ driving routes. There are many other examples of COF fostering the persons who receive services to be volunteers within the three counties which COF services. Volunteerism provides recipients of COF’s services who are accustomed to being in the “receiving” mode to instead become “givers.” In so doing, integration and inclusion occur naturally along with enhanced self-esteem and pride in accomplishments. As matter of fact, if you are citizen of Burlington; Osage City; or Ottawa, seeing people who receive services from COF volunteering in your community is a common, routine sight. You come to expect it, to take it for granted. That’s exactly how it should be!