The State Community Integration Index (SCII)
A multi-domain assessment of how all 50 states are meeting — or failing to meet — the legal mandate of Olmstead v. L.C. and the Americans with Disabilities Act.
The State Community Integration Index (SCII) measures how all 50 states are meeting — or failing to meet — their legal obligation to support people with disabilities in living, working, and participating fully in their communities, assessing state performance across six domains: institutional population burden, HCBS infrastructure, Olmstead compliance, criminal justice diversion, housing and economic self-determination, and civil rights infrastructure. Because the distance between disability rights on paper and disability reality in practice is rarely visible in a single dataset, the SCII synthesizes data across nursing facilities, psychiatric hospitals, jails, group homes, and homeless populations to produce the most comprehensive picture of institutionalization currently available at the state level. It is built for advocates who need evidence, professionals who need context, policymakers who need accountability, and people with disabilities and their families who deserve to know exactly where their state stands.
The Problem the Index Addresses
Twenty-five years after the Supreme Court’s decision in Olmstead v. L.C. established that the unnecessary institutionalization of people with disabilities constitutes unlawful discrimination, the legal framework remains intact — but its realization across the country is anything but uniform. In some states, the mandate has driven genuine structural transformation: waitlists have shrunk, institutions have closed, and community living has become the operational default. In others, the principle sits in a policy document while thousands of people with disabilities wait years for services, cycle through jails and emergency rooms, or lose their housing and disappear into systems never designed to support them. The boundary between community living and institutionalization is not fixed by law alone — it is shaped continuously by the policy decisions states make about where to invest, what to build, and who to prioritize. Despite growing attention to disability policy, existing rankings and scorecards tend to measure only one dimension of this problem: HCBS waiver access, or mental health system capacity, or employment outcomes for people with intellectual and developmental disabilities. None captures the full institutional continuum — the range of settings, from nursing facilities and psychiatric hospitals to jails, large group homes, and chronic homelessness, through which people with disabilities are separated from community life. Institutionalization is not a single setting. It is a continuum — and a state’s commitment to community integration must be measured across every point on that continuum. The State Community Integration Index was built to do exactly that.
The Five Faces of Institutionalization
How We Define the Problem
When most people hear the word “institutionalization,” they picture a single image: a locked ward, a state hospital, a facility set apart from the community by fences and distance. That image is not wrong — but it is incomplete. Institutionalization, as the SCII understands it, is not defined by a building. It is defined by the degree to which a person’s life — their choices, their relationships, their daily movements, their sense of self — is determined by a system rather than by themselves. By that measure, institutionalization occurs across five distinct settings, each operating through different mechanisms, different legal frameworks, and different points of entry. A state that has closed its psychiatric hospitals but maintains a ten-year HCBS waitlist has not solved the problem. It has relocated it.
Nursing Facilities (for individuals under 65 with disabilities) Nursing facilities are most commonly understood as settings for elderly individuals requiring medical care. But a significant and frequently overlooked population inside these facilities consists of working-age adults with physical disabilities, acquired brain injuries, and chronic health conditions who entered not because community alternatives were unavailable in principle, but because they were unavailable in practice — because HCBS waitlists were too long, because housing was inaccessible, or because a crisis left no other option. For this population, nursing facility placement is not a clinical outcome. It is a systems failure with a permanent address.
State Psychiatric Hospitals and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IIDs) State psychiatric hospitals and ICF/IIDs represent the most historically recognized face of institutionalization in disability policy — the settings that Olmstead most directly addressed. Despite decades of deinstitutionalization, both remain in active use. As of 2023, the Treatment Advocacy Center documented a historic low of 36,150 state psychiatric hospital beds nationally, yet 52% of those beds are occupied by individuals committed through the criminal legal system rather than voluntarily seeking treatment. ICF/IIDs continue to house individuals with intellectual and developmental disabilities in congregate settings where daily life is structured by facility schedules rather than personal preference. Their continued existence — and the funding streams that sustain them — represents an ongoing policy choice, not an administrative residual.
Large Group Homes (settings of 6 or more residents not chosen by the individual) The reclassification of large group homes as “community-based” settings has been one of the most consequential definitional maneuvers in disability policy. A group home is not, by definition, a community setting. When six or more individuals with disabilities are placed together in a residence they did not choose, with staff they did not hire, following routines they did not design, the physical address outside an institution does not change the functional reality inside it. The CMS HCBS Final Rule (2014) recognized this by establishing characteristics that community settings must demonstrate — including opportunities for choice, integration, and independence. The SCII applies those standards, not the address alone, to determine whether a setting counts as community living.
Jails and Prisons (with focus on individuals with serious mental illness, IDD, and traumatic brain injury) The criminalization of disability is one of the most extensively documented and least addressed crises in American public policy. The Treatment Advocacy Center estimates that more than 356,000 individuals with serious mental illness are incarcerated in jails and prisons — a population ten times larger than that housed in state psychiatric hospitals. Individuals with intellectual and developmental disabilities and traumatic brain injuries are similarly overrepresented in correctional settings, frequently because the community systems that should have supported them were absent, underfunded, or inaccessible. Incarceration in this context is not a criminal justice outcome. It is the terminal point of a service system failure — the institutionalization that occurs when every earlier intervention did not.
Chronic Homelessness (among individuals with disabilities) Homelessness is institutionalization without walls. For individuals experiencing chronic homelessness — defined federally as continuous homelessness for one year or more accompanied by a disabling condition — the absence of stable housing is not merely a housing problem. It is a manifestation of the same system failures that produce nursing facility placements and incarceration: the absence of affordable accessible housing, the erosion of community supports, and the exhaustion of informal caregiving networks. The 2024 HUD Annual Homeless Assessment Report documented 152,585 chronically homeless individuals nationally, the majority of whom have a disabling condition. These individuals are not outside the disability service system — they are the evidence of where that system ends.
What We Measure
The SCII evaluates each state across six domains. Together, these domains answer a single question: does this state build the conditions that make community living possible — or the conditions that make institutionalization inevitable? Each domain carries a point value reflecting its contribution to that answer. A state’s total score out of 100 is its composite measure of how well it is delivering on the promise of Olmstead.
Domain 1: Institutional Population Burden
20 points — How many people are living in institutional settings right now?
This domain counts. Across all five institutional settings — nursing facilities, psychiatric hospitals, ICF/IIDs, jails and prisons, and chronic homelessness — it measures how many people with disabilities in each state are living outside of community life, calculated per capita so that large and small states are compared fairly. A state with a high institutional population burden is not necessarily a state with bad intentions. It is a state where the infrastructure of community living has not kept pace with the people who need it.
Example indicator: Number of working-age adults (under 65) with disabilities in nursing facilities per 100,000 state residents.
Domain 2: HCBS Infrastructure
20 points — How strong are the community alternatives to institutional care?
Home and Community-Based Services (HCBS) are the primary policy mechanism through which states fulfill the Olmstead mandate. This domain measures whether those services are actually accessible — not just whether they exist on paper. It examines waiver enrollment and waitlist size, how long people wait from eligibility determination to receiving a service, whether the state offers self-directed care options, and whether HCBS spending represents the majority of the state’s total long-term care investment. A waiver program with a ten-year waitlist is not a community alternative. It is a delayed institutionalization.
Example indicator: HCBS spending as a percentage of total Medicaid long-term services and supports spending.
Domain 3: Olmstead Compliance
15 points — Is the state actively working to fulfill its legal obligation?
Olmstead is not self-executing. States are required to have a plan — and more importantly, to implement it. This domain evaluates both the formal structure of a state’s Olmstead plan (does it exist, is it current, does it include measurable timelines?) and the substantive evidence of implementation (are people actually moving from institutional settings into the community?). It also applies a judicial posture modifier: states operating under court-enforced settlements receive credit for accountability, while states whose Olmstead protections have been weakened by appellate courts receive a penalty that reflects the structural damage to their legal compliance framework.
Example indicator: Whether an active, independently monitored Olmstead Plan with binding benchmarks is in place.
Domain 4: Criminal Justice Diversion
15 points — Does the state intervene before disability becomes criminalized?
The pipeline from untreated disability to incarceration is well-documented and largely preventable. This domain measures whether a state has built the infrastructure to interrupt that pipeline: mobile crisis response teams that can reach people in psychiatric emergencies without law enforcement, 988 Suicide and Crisis Lifeline in-state answer rates, mental health courts that offer treatment instead of incarceration, and pre-arrest diversion programs. It also examines whether people leaving incarceration can access HCBS services and supports — because reentry without community services is a direct path back to institutionalization.
Example indicator: Percentage of the state population covered by mobile crisis response services.
Domain 5: Housing & Economic Self-Determination
15 points — Can a person with a disability afford to live independently?
Community living requires two things above all others: a place to live and an income sufficient to sustain it. This domain measures both. On the housing side, it examines the availability of permanent supportive housing, the state’s SSI supplement amount, and access to disability-designated housing vouchers. On the economic side, it measures whether the state has eliminated the use of Section 14(c) subminimum wage certificates — which legally permit employers to pay workers with disabilities below the minimum wage — and the rate at which people with disabilities are achieving competitive integrated employment. A state that permits subminimum wage employment is a state that has not fully committed to the economic participation that community living requires.
Example indicator: Whether the state has fully eliminated subminimum wage (14(c)) employment by statute.
Domain 6: Voice, Oversight & Civil Rights
15 points — Do people with disabilities have the institutional power to hold the system accountable?
Rights without enforcement mechanisms are aspirations. This domain measures the infrastructure through which people with disabilities can identify violations, demand accountability, and drive change. It examines the funding and capacity of Protection and Advocacy (P&A) organizations — federally mandated disability rights legal organizations present in every state — as well as Independent Living Centers, state long-term care ombudsman programs, and whether the state has enacted its own disability civil rights protections beyond the federal floor. A state where P&A organizations are underfunded, ILCs are sparse, and no state-level enforcement exists is a state where violations can occur without consequence.
Example indicator: Per-capita funding for the state’s federally designated Protection and Advocacy organization.
The Tier System
How States Are Ranked
| Tier | Score | Designation |
|---|---|---|
| 🟢 Tier 1 | 80–100 | Leading — Substantial alignment with Olmstead mandate |
| 🟡 Tier 2 | 60–79 | Progressing — Meaningful infrastructure with documented gaps |
| 🟠 Tier 3 | 40–59 | Lagging — Significant structural deficits requiring reform |
| 🔴 Tier 4 | Below 40 | Critical — Systemic failure of community integration mandate |
Tier assignment serves as a helpful assessment, not as a punishment.
The Judicial Posture Subsystem
A Critical Modifier
- Active DOJ enforcement signals federal recognition that a state has failed — but also signals that remediation is underway
- More troubling: states operating under appellate rulings that have narrowed Olmstead (such as the Fifth Circuit’s 2023 reversal in United States v. Mississippi) have no enforcement mechanism even when violations occur
- The SCII applies a modifier to capture this distinction:
| Posture | Modifier |
|---|---|
| Protected | +2 pts |
| Neutral | 0 pts |
| Active Enforcement | -2 pts |
| Judicially Narrowed | -5 pts |
The Lived Reality Survey
Your Voice in the Index
Data tells part of the story. People with disabilities, their families, and the professionals who work alongside them tell the rest.
Every score in the SCII is built from official sources — federal datasets, state agency reports, court records, and policy documents. That data is important. It is also limited. It measures what governments report about themselves. It captures what was filed, published, and submitted — not necessarily what was experienced. A state can report a waitlist of 2,000 people while advocates on the ground know that thousands more have stopped applying because they stopped believing the system would respond. A state can publish an Olmstead plan while the individuals it was written for have never heard of it, never been offered a transition, and never been asked what they want.
The Lived Reality Survey exists to make that gap visible.
Anyone with direct knowledge of how disability services function in their state is invited to contribute: people with disabilities navigating the system firsthand, family members and caregivers, disability advocates, rehabilitation counselors, social workers, attorneys, and benefits specialists. The survey asks what official data cannot — how long you actually waited, what you were actually told, what was available when you needed it, and what was not.
Lived Reality Survey responses are reported alongside the composite SCII score for each state — not merged into it. This is an intentional design choice. When official metrics and lived experience align, that alignment is meaningful. When they diverge, that divergence is the finding. It tells us not just where a state’s systems are failing, but where the data being used to evaluate those systems is failing too.
Your experience matters. It should be included in this Index.
Contribute to the Lived Reality Survey →
Methodology and Transparency
How We Score, Where We Source
Every number in the SCII has a source, and every source is visible. The Index is built on a straightforward commitment: if we cannot show where a score came from, we do not use it. If a data point is unavailable for a state, we say so explicitly rather than fill the gap with an estimate. Transparency is not a feature of this methodology — it is the foundation of it.
Where the Data Comes From
The SCII draws from federal datasets, independent research organizations, advocacy-sector scorecards, and state agency documents. No single source is treated as authoritative on its own. Where sources overlap, we note the agreement. Where they diverge, we note the tension and explain how it was resolved.
Federal and Government Sources
- KFF (Kaiser Family Foundation) — Medicaid HCBS Annual Surveys; state-level LTSS spending data
- Centers for Medicare & Medicaid Services (CMS) — Nursing Home Compare; HCBS settings data; waiver program documentation
- HUD Annual Homeless Assessment Report (AHAR) — Point-in-time counts of chronic homelessness by state, including disability status
- Bureau of Justice Statistics — Incarceration data; mental illness prevalence in jails and prisons
- Substance Abuse and Mental Health Services Administration (SAMHSA) — Uniform Reporting System; state psychiatric hospital census
- Administration for Community Living (ACL) — Protection & Advocacy funding data; Independent Living Center program data
- DOJ Civil Rights Division — Olmstead enforcement records; settlement agreement status; consent decree monitoring reports
Independent and Advocacy Sector Sources
- Treatment Advocacy Center — State-by-state psychiatric bed data; criminalization of mental illness reports
- ANCOR & United Cerebral Palsy — Case for Inclusion — Annual I/DD services scorecard across six issue areas
- The Arc — State of the States in Intellectual and Developmental Disabilities — ICF/IID population data; HCBS waiver enrollment
- State Medicaid agencies and published Olmstead Plan documents — Direct source verification for compliance indicators
What We Commit To
Full source attribution. Every indicator in every state profile identifies the dataset it came from and the year of that data. Readers can verify, challenge, and build on what we publish.
Honest disclosure of gaps. Where data is unavailable, outdated, or inconsistent across sources, state profiles say so explicitly. A disclosed gap is more useful than a confident estimate.
Public methodology versioning. The SCII methodology is a living document. The current version is v2.0, refined following a five-state pilot phase. All prior versions remain publicly available so that changes between editions are traceable.
Annual updates with year-over-year comparison. The Index will be updated each year as new federal data becomes available. Each state’s score will be reported alongside its prior-year score, allowing readers to track whether states are advancing, stalling, or regressing.
Methodology Documentation
No measurement tool is complete, and a methodology that does not name its own limits is not one worth trusting. The SCII is designed to be rigorous, but rigor includes honesty about what the data cannot reach. The following limitations are not reasons to dismiss the Index — they are the boundaries within which its findings should be read, and the gaps that future iterations are actively working to close.
Data Lag Federal datasets typically operate on a 12 to 24 month delay between the period they describe and the date they are published. A score published in 2026 may reflect 2024 conditions in some domains and 2023 conditions in others. Where data vintage affects interpretation, state profiles note the year of each data point explicitly. The SCII reflects the most current publicly available data — not necessarily the most current reality.
Hidden Institutionalization The five settings measured by the SCII are those for which data exists at a national scale. But institutionalization also occurs in places that federal datasets do not reliably reach. Families providing round-the-clock care without any formal support — not by choice but by necessity — are living a form of isolation that the numbers do not count. Individuals with disabilities on tribal reservations navigate a distinct and chronically underfunded service landscape that aggregate state data obscures. People held in immigration detention facilities, many of whom have significant disabilities, fall almost entirely outside state disability service reporting. These populations are not invisible because they are rare. They are invisible because the systems that failed them did not record the failure.
Intersectional Disparities The SCII scores states as a whole. It does not yet capture how outcomes are distributed within states across race, ethnicity, LGBTQ+ status, primary language, or immigration status. A state that performs well on average may be producing those averages by serving white, English-speaking, urban residents well while Black, Indigenous, and Latino people with disabilities remain in institutional settings at disproportionate rates. A separate Equity Sub-Index is currently in development to address this gap directly, examining whether community integration is being achieved equitably — or only on paper.
Definitional Variation States do not define “community-based” consistently. A setting that one state classifies as a community residential program may function in ways that are indistinguishable from an institution — controlled schedules, congregate living, no meaningful choice. The SCII applies the definitions established by the CMS HCBS Final Rule (2014) as its controlling standard, evaluating settings by what they deliver rather than what they are labeled. Where states’ own classifications appear inconsistent with those standards — as revealed by ongoing HCBS heightened scrutiny reviews in several states — this is noted in state profiles.
Federal-Level Changes The SCII measures state performance, but states do not operate in isolation from federal policy. The dismantling of the Administration for Community Living, the largest staffing cuts in Social Security Administration history, and the withdrawal of the proposed federal rule to phase out subminimum wage employment under Section 14(c) are all federal-level changes that create baseline shifts affecting every state simultaneously. These shifts are not captured in state-to-state comparisons — they are the water that all states are swimming in. The SCII blog accompanies the Index with ongoing federal policy analysis precisely because state rankings alone cannot convey the full picture of what is happening to disability services in the United States right now.
About the Survey Architect
The State Community Integration Index was created by Candace Metcalf, CRC, LPC, who has a Master’s in Applied Sociology and a Master’s in Clinical Counseling with experience working in the Rehabilitation industry. This background helps shape the Index. Her sociological training helps her see these experiences as predictable results of institutional design that can be measured, analyzed, and changed.
Her professional background spans rehabilitation, disability policy, and research, with a consistent focus on helping individuals navigate the public service systems that were built to support them but too often do not. That focus is the origin of this Index. The SCII did not emerge from an abstract interest in data. It emerged from direct experience with the gap between what disability policy promises and what people with disabilities actually encounter — and from the conviction that making that gap visible and measurable is a precondition for closing it.
Instructions for Utilizing this Survey
For Advocates State profiles give you the evidence base for campaigns that need to go beyond anecdote. When a legislature is debating HCBS funding, a SCII domain score tells you exactly where the gap is and how your state compares to peers investing more. When a DOJ investigation is warranted, the Index identifies the indicators that support that case. When a budget cut is proposed, the institutional population burden score shows what the human cost of that cut is likely to be. Use the data to focus your campaigns, target your litigation, and make the structural argument that specific policy choices produce specific human outcomes.
For Rehabilitation and Disability Professionals The clients you serve do not experience disability policy in the abstract — they experience it through waitlists that move or don’t, housing that exists or doesn’t, and systems that respond or leave them waiting. The SCII gives you the systemic context behind what you are seeing in your caseload. When a client cannot access a waiver, the HCBS infrastructure score tells you whether that is a local problem or a state-level structural failure. When a client cycles through crisis services and emergency rooms, the criminal justice diversion score tells you what the system around them is — and is not — built to do. Understanding the system your clients are navigating is part of understanding your clients.
For Policymakers Every state in the SCII is compared to every other state, which means no jurisdiction can evaluate its own performance in isolation. If your state is in Tier 3 on HCBS infrastructure while a neighboring state with a comparable population and budget has built its way to Tier 1, the Index tells you that the gap is a policy choice — not an inevitability. Use the domain-level breakdown to identify exactly where investment is needed. Use peer state profiles to find models worth replicating. Use the Olmstead compliance indicators to assess where your state’s legal exposure is greatest and where proactive reform is less expensive than reactive litigation.
For People with Disabilities and Families You have a legal right to live in the community of your choice, with the supports you need to do so. That right was affirmed by the Supreme Court in 1999 and has been reaffirmed in courts and consent decrees across the country in the decades since. The SCII exists, in part, so that you can see clearly whether the state you live in is honoring that commitment — or whether the waitlist you are on, the services you cannot access, and the options you were never offered are the result of deliberate structural choices that can be named, measured, and changed. Your experience is not just personal. It is evidence of where the system stands. This Index is one way to make that evidence visible.
Citation suggestion (for academic and policy use):
Suggested citation: Candace Metcalf. (2026). The State Community Integration Index (Methodology v2.0). Rehabilitation Reform. https://rehabilitationreform.com/scii
