nasddds/nasmhpd joint legal division barbara brent nasddds nasddds national association of state...

Moving Forward Supporting People With Disabilities and Their Families

NASDDDS/NASMHPDJoint Legal Division

Barbara BrentNASDDDS

NASDDDSNational Association of State Directors of Developmental Disabilities Services

We Have Made Great Progress From This……

to….NASDDDS National Association of State Directors of Developmental Disabilities Services

WORK

PLAY

FRIENDS

This…

State Budget Shortfalls are Improving but,…

.Growth of 8.3% per Year Would not Restore Losses from Recession Until Fiscal Year 2019

National Association of State Directors of Developmental Disabilities Services

Shifting Medicaid Environment

New State Plan Service Options 1915(i) HCBS state plan option 1915(k) Community first Choice Option Balancing Incentive Program stimulate access

to community supports, MFP CMS efforts to define community settings Broadened use of capped support waivers Focus on Medicaid-Medicare dual eligibles Affordable Care Act: health homes, accountable

care organizations, etc.


Confronting the “Brutal Truth”- Then Moving Forward

The Waiting List

Growth in public funding will slow

People WaitingFor Services

Residential Capacity

Growth Needed

155,059 Lakin240,000 Kaiser

466,809 24.6%

15,000,000

30,000,000

45,000,000

60,000,000

75,000,000

2000 2005 2010 2015 2020 2025 2030

Source: U.S. Census Bureau, Population Division, Interim State Population Projections, 2005

Females aged 25-44 Individuals 65 and older

Workforce will not be able to keep up with demand

NASDDDS National Association of State Directors of Developmental Disabilities Services

State Responses to the Challenge

In the worst times, service reductions and rate reductions When there is time for thought:

1. Focus on rebalancing2. Focus on sustainability

Supporting Families Getting people a job Looking beyond residential- or a different kind of

residential3. Focus on Equity

Individual Budget Allocation-with full self determination or allocations to leverage

Fair and equitable rates4. Managed care

▪ Specific for lifelong disabilities and I/DD specifics (achieved in some states), community, self direction and employment


States are Rebalancing

@29,000 2011

Source: UMN RTC/ICI


12 States Have No Public Institutions >16

Closure Date StateGeneral Population

1 1991 New Hampshire 1,315,000

2 1991District of Columbia

582,000

3 1993 Vermont 624,000

4 1994 Rhode Island 1,068,000

5 1996 Maine 1,322,000

6 1997 Alaska 670,000

7 1997 New Mexico 1,955,000

8 1998 West Virginia 1,818,000

9 1999 Hawaii 1,285,000

10 2009 Oregon 3,641,000

11 2010 Michigan 10,079,985

12 2011 Alabama 4,779,736

UMinn RISP Rpt. 2010

States are Rebalancing


StatePopulation

1 Texas 4,207 x

2 New Jersey 2,703 x

3 Illinois 2,111 x

4 Calif. 2,070 x

5 New York 1,981

6 North Carolina 1,598

7 Virginia 1,153 x

8 Ohio 1,329 x

9 Mississippi 1,324 DOJ

10 Pennsylvania 1,189

11 Louisiana 1,124 x

12 Arkansas 1,052

StatePopulation

1 Alaska 173

2 Arizona 115

3 Colorado 67

4. Delaware 70

5 Idaho 62

6 Indiana 192

7 Kentucky 169

8 Maryland 144

9 Minnesota 29

10 Montana 55

11 Nebraska 173

12 Nevada 47

13 North Dakota 115

14 Rhode island 17

15 South Dakota 144

16 Wyoming 83

Source: UMN RTC/ICI

16 Stateshave <200 peoplein large facilities

x downsizing initiatives

UMinn. RISP Rpt. 2010

States Are Moving Away from Facilities-not usually due to the law or the money as the first goals anymore


Thinking for the Long Term About Cost

Type of ServiceCost per Person

20 yrs.

Cost

30 yrs.

Cost

ICF/MR

Institution

$238,500

$4,770,000 $7,155,000

HCBS

24hr staffed

Residential

$150,000

$3,000,000 $4,500,000

Shared Living

(Adult Foster

Care)

$50,000 $1,000,000 $1,500,000

Supports in Own or Family

Home$25,000 $500,000 $750,000


Sustainability depends on how good we are at

supporting families and

getting people jobs.

Nancy Thaler, NASDDDS


Highest Cost

Lowest Cost

People with Developmental Disabilities(1% of the population)

Big House State Op ICF-MRs

CommunityICF-MRs

HCBS WaiversComprehensive & Specialty Waivers

Supports Waivers

State Funded Family Support

Services

DEMAND

Nudging the System

NASDDDS National Association of State Directors of Developmental Disabilities Services

The idea is to nudge a system down the incline to reduce per person expenditures.

The idea is to nudge a system to be person-centered, to support families, and involve people in their community.

Employment

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

16 + PRF

52456 50034 47329 45942 44066 42835 41653 39098 38172 36650 35035 32909

7+ and Nursing Homes

78086 78669 85013 89504 88085 89351 83670 83034 88753 84933 79504 88056

1-6 Commu-nity

108844 114546 124469 135322 135571 135569 142918 156610 157082 157765 160477 158621

Own/Host Home

90791 96890 110514 120930 128966 136356 147014 136529 139688 152631 154135 162842

Family Home

325650 355192 391859 446220 482479 500004 503641 533048 569020 552559 588594 599152

50,000

150,000

250,000

350,000

450,000

550,000

650,000

750,000

850,000

950,000

1,050,000

Residence of all IDD Service Recipients 1998 to 2009

Year

Resid

ents w

ith I

DD

Sustainability Means Supporting Families

Arizona 86%Calif. 71%Florida 70%Idaho 75%S.C. 72%

Nevada 69%Delaware 68%NJ 68%Wash 67%Louisiana 66%Hawaii 65%Mass. 62%NY 62%West Virg.60%

57.5%

Lakin et.al. RISP 2009 –UMinn.

Attorneys: Supporting Your Client

Most are eager to move to more inclusive settings and innovation---and it isn’t easy- multiple customers: department, executive and legislative branches, providers, families, self advocates

May not share the same belief that the safest route is always the best route. It is a matter of balance

How can I help you achieve what your goal is today?

What are your risks? What will help mitigate

those risks? CRIPA- - -it is about

community- it is about the ADA


Supporting Family Caregivers

Family support is more than respite

It is foundational It is a life journey It is inclusive Family support is a

rich array of services, relationships and connections

States are Focusing on Employment

0%

20%

40%

60%

80%

100%

2009 –UMass Boston ICI ID/DD Agency Survey

Success in employment varies widely 2009

Washington State (88 %)Oklahoma (60%)Connecticut (54%)Louisiana (47%)New Hampshire (46%)


Resource

Allocation, Fair and Equitable Rates and Self

Direction


Searching for Equity and Fairness –And Self Direction!Individual Allocations with Consumer-Directed Options

Individual Resource Allocation Equity and Fairness Predictable costs

Consumer-Directed Services and/or Fiscal Intermediary Supports Hire and fire staff, hire relatives, neighbors or other trusted

people, control a budget Thirteen states offered individual budgets and consumer

control statewide for at least some individuals in Jan. 2009

Other states use fiscal intermediary and the ability to hire and fire, but do not provide for full consumer directed budgets

Some states are using fair and equitable rates- same rates for same services


Managed Care Brings Opportunities

Opportunities: Reduce reliance on facility based services Integration with medical, behavioral and long term care

services and supports Control costs Address the waiting list Innovation- offering more types of services and supports

Concerns Need to keep the DD expertise and oversight Focus on outcomes related to employment, inclusion and

life long services and supports Supporting people with the most significant support needs

in the community Keeping medical important and improve access and

coordination - but community in the forefrontNASDDDSNational Association of State Directors of Developmental Disabilities Services

Medicaid Managed Long Term Care-does not include all the states that have acute managed care

Arizona -1115 Michigan-B/C counties Vermont-1115 Wisconsin-B/C counties Texas Star Plus-B/C North Carolina - B/C all

counties rolling out this year

New York-will now be a 1915 (b) (c)

New Hampshire

Kansas, I/DD delayed one year

Kentucky ? Illinois -1115

delayed New Jersey -1115

approved

More with behavioral health


Responses to the Challenge-Eyes on the Prize

1. Focus on rebalancing – reducing reliance on facility based programs

2. Focus on sustainability Supporting families Getting people a job Looking at new ways to support people at home and in

communities

3. Focus on individual budget allocations, consumer self direction, etc.

4. Managed care Keep the values, outcomes, identity and community-

support more people well.NASDDDSNational Association of State Directors of Developmental Disabilities Services

Are We Ready for the New World?

Can we start early and continue on the journey with people – life planning changes more frequently for all of us?

Can we assume community in all we do? Can we become nimble in helping people navigate

the community- the public system- our own communities?

Can we support everyone in learning new skills? The law according to community, compliance according to community, the world according to community.

Compliance is important- and helping people get a life is the core of the work.


Christopher Says “Yes!” and A. Says Keep Working at It..

First job starts this summer!

Supported with integrated acute, long term care services specific to dd. Family support is more than respite.

No residential any time soon.

Lives with his family- integrated acute, long term and behavioral supports. Hourly habilitation, behavior support, community inclusion.


Thank you!Barbara Brent

National Association of State Directors of Developmental

Disabilities [email protected]

Direct Line: 703-896-0043Web Site: http://www.nasddds.org


mailto:[email protected]

http://www.nasddds.org/

http://www.nasddds.org/

nasddds/nasmhpd joint legal division barbara brent nasddds nasddds national association of state...

Documents

lifelong disabilities

hcbs state plan option

new state plan service

community settings

service reductions

managed care specific

accountable care organizations

waiting list growth