Gauging the Use of HCBS Supports Waivers for People with
Intellectual and Developmental Disabilities: Final Project Report
APPENDIX B. STATE-BY-STATE CASE STUDY RESULTS
PDF Version (66 PDF
pages)
TABLE OF CONTENTS
- FLORIDA
- MISSOURI
- OKLAHOMA
- OREGON
- PENNSYLVANIA
- TENNESSEE
Introduction
Floridas Family and Supported Living (FSL) Waiver was initiated in
October 2005 with enrollment quickly growing to 2,650 recipients. The focus of
these supports is to provide services to children and adults with disabilities
living at home. Today there are 5,921 people enrolled in the supports waiver
and 26,079 others served through the states comprehensive waiver.
Method
In September and October 2006, the Human Services Research Institute
(HSRI) staff visited Florida to conduct face-to-face consultations with key
informants and also conducted discussions by telephone with additional
informants. The individuals included in these conversations were: (a) state
Agency for Persons with Disabilities (APD) staff including the state director,
waiver manager and others along with personnel with the Florida Medicaid,
Bureau of Medicaid Services, Developmental Disabilities Services Division; (b)
representatives from interests outside the state agencies including the chair
for community living and family committee from the Developmental Disabilities
Planning Council and several families representing regional Family Care
Councils; (c) service providers associated with the Florida Association of
Rehabilitation Facilities; (d) independent support coordinators who perform
service planning and monitor service delivery; and (e) staff of the Delmarva
Foundation which manages Floridas statewide waiver quality
assurance/improvement program.
Results
What follows are results of the conversations. First, information is
presented to describe the policy goals of the waivers, information on waiting
lists, and the fundamental waiver operations. Second, views offered by the
informants are presented related to: (a) access to the waiver; (b) waiver
operations such as budget allocations, service planning, service delivery, and
safeguards; (c) outcomes; and (d) key issues in play.
Florida Policy Goals
Question: What are the major policy goals of the supports
waivers and how successful have the waivers been in meeting them?
- Cost containment and budget related goals were a primary focus of the
FLS waiver. The FSL Waiver employs a funding cap in order to serve more people
with fewer dollars than would ordinarily possible.
- Goals related to addressing the waiting list are also a primary
focus. When the state settled the Prado-Steiman litigation, it committed
to serving all eligible individuals who were on the waiting list as of June
1999. This goal was met, and the number of people receiving waiver services
grew from 13,800 in 1999 to over 24,000 in 2004. Florida Governor Jeb Bush was
instrumental in securing additional funding during this period and continues to
support funding increases for developmental disability services.
- However, despite tripling funding for developmental disabilities
during the period and substantial and necessary expansion of the comprehensive
waiver, the waiting list climbed to 15,000 people. The FSL Waiver emerged as a
means to support individuals and families who are on the comprehensive waiver
waiting list by offering them a more limited package of in-home and other
supports. In February 2007 the Florida legislature has continued its debate on
the waiting list and additional potential future funding.
- Consumer-direction and person-centered planning goals are not primary
goals of the FSL Waiver. The state is interested in flexible budget usage and
improving its ability to assess individual support needs. Florida operates a
pilot Centers for Disease Control and Prevention waiver that serves about 1,000
people and incorporates self-direction.
- Rebalancing the long-term care system and refinancing community
services have not been primary policy goals.
- The state also is pressing for increased use of supported employment
and supported living services.
Wait-lists
Question: How many people are on the consolidated (i.e., all
wait-lists for developmental disabilities services) wait-list?
- In 2005, after a strong enrollment effort, 5,600 people were admitted
to the waiver, reducing the wait-list to 6,200. To promote the waiver,
11,000-12,000 letters were sent to potential enrollees. But the wait-list has
climbed back to about 12,000 due to: (a) continuing increases in the numbers
each year who come forward seeking services; and (b) delayed impacts of
population disruption and population migration due to hurricane impacts.
- State officials expect that there will be 9,000-10,000 people on the
waiting list at years end.
- In July 2006, the Florida Office of Program Policy Analysis and
Government Accountability called for APD to improve its management of the
waiting list with more regular review, updating, and identifying service needs.
APD was encouraged to develop a multi-year plan for addressing the waiting list
for waiver services that considers the length of time individuals have been on
the waiting list, how soon the individual is expected to need waiver services,
the expected level of services to be provided, and whether the individual is
receiving services from other waivers or programs. In February 2007, the
Florida legislature was weighing additional funding to help people move from
the wait-list.
- People enrolled in the FSL Waiver may maintain their position waiting
for the comprehensive Developmental Services Home and Community-Based Services
(HCBS) Waiver (the comprehensive waiver).
Question: How are wait-lists maintained?
- Waiting lists are maintained for each waiver. State area offices
process enrollment requests and maintain a consolidated wait-list that is also
shared with the APD central office. Individuals apply for APD services and are
later identified as potential waiver enrollees. A preliminary needs assessment
is used by the state to select individuals who are on the waiting list for the
FSL Waiver. When a waiver opening becomes available, the person is assigned a
support coordinator. The central APD office keeps a running tally of the
waiting list counts as information flows in from the area offices.
Question: How long generally is the wait?
- The average time on the waiting or interest list before an individual
is enrolled is now five years or less, down from eight years in 2003. Some 81
percent of the individuals waiting are age 30 and under. Most of these
potential enrollees have an intellectual disability. In January 2007,
Floridas APD was anticipating a $230 million deficit through the next
year and a half. The Florida Legislature in February 2007 continued to examine
the wait-list. Since then, Floridas new Governor Charlie Crist released
his budget recommendations for FY 2007-2008 that includes $119 million to cover
the growing demand for waiver services through increased utilization from
existing customers, and to provide waiver services to customers transitioning
from the developmental services institutions.
- Governor Crist also earmarked funds to take care of citizens with
developmental disabilities that find themselves in extreme need due to a
caretaker or housing crisis. Over $7 million will be used to care for 500 new
crisis customers in the upcoming year and another $6.7 million will pay for the
crisis customers that will enter the program this year.
- In addition, the proposed budget provides $6.6 million to allow the
agency to serve more people in its Mentally Retarded Defendant Program and may
take steps to reduce it.
Basic Operations
Question: How are people selected for enrollment?
- The enrollment process for the FSL Waiver is a step by step process
that is coordinated by the central office and area office to track and guide
applicants through the enrollment process. Interest letters are used by the
area office with screening questions to check for HCBS eligibility criteria. A
preliminary needs assessment is used to select individuals for the support
waiver. Foster children with individual and other developmental disabilities
(I&DD) and referrals with I&DD from the corrections system are covered
by the comprehensive waiver but entry to the comprehensive waiver is now
restricted due to funding limitations. In the current FY support waiver
enrollment is also severely limited due to funding limitations. When the
support waiver began, the enrollment process was controlled by the central
office but this process has been moved to the area offices throughout Florida.
Question: Is there descriptive information available on the
people served in the supports waiver (e.g., age, primary disability, living
arrangement, functional status, caregivers)? Is systematic information
available regarding waiver impacts?
- The APD annual report and brochures broadly defines profiles of those
served in the supports waiver.
- More descriptive information is available to describe individual
characteristics such as age, primary and secondary disability, and living
arrangement.
- Systematic information about the impact of the supports waiver on is
produced by the statewide quality assurance program.
Question: How is quality assurance and quality management
managed?
- The same quality management architecture is employed for both
waivers.
- Family Care Councils have been organized by region. The councils have
many families of individuals who are relatively new to waiver services. The
councils provide information to families and serve as a conduit of information
and experience about the waiver among families. (See the booklet Planning
Ahead which is available on-line at http://www.fddc.org or the brochure titled
Protecting Legal Rights: Its in Your hands! available at
http://apd.myflorida.com.
Question: How are individual service plans developed?
- Independent service coordinators meet with the person and their
family or representative/legal guardian to complete needs assessments; identify
supports needed and develop a plan to address stated needs.
- As a practical matter, the service coordinators often feel that if an
individual wants a particular service or support, it can be submitted in the
plan even though it may not be approved.
Question: How are individual allocations set?
- In September 2006, the waiver funding cap was increased to $14,792,
up from $14,282. Previously, varying soft caps per person were
applied but have been eliminated in favor of an overall total dollar cap per
person. Exceptions are not made to the overall total support waiver cap.
- Individual assessments are conducted using a tool called the
Individual Cost Guidelines. It determines the recipients specific
resource allocation for waiver funds for recipients receiving supports.
- The individual has knows the funding allocation before planning
starts. However, some informants expressed the concern that sometimes the
amount of the funding allocation is not made known to families and individuals
before a plan is created.
Question: What decision-making authority do
individuals/families have over the budget?
- They can plan within capitated dollar limit and determine services
and supports needed. Among people with two full years of plan development the
average plan cost was approximately $9,000 but the actual expenditures averaged
about $4,000. Understanding this pattern and the reasons driving it may take
several years, in part because of the rapid growth and relative newness of the
support waiver.
Question: Who has primary responsibility for developing
the service plan?
- Individual support coordinators have primary responsibility.
- Among the service planners, the average caseload is 36 individuals
per service planner, ranging from 18 to 42 individuals per planner.
- In Florida, people do not have paid outside assistance available to
them during the planning process to help design the service plan.
Question: Does the service planning include a distinct risk
assessment process to identify and address identified risk?
- Service planning does not include a distinct risk assessment process
to identify and address identified risks and negotiated risk agreements are not
used.
Question: Is the process the same or different from that used
in the comprehensive waiver?
- Yes, it is the same process. The FSL Waiver has fewer services and
supports and the resulting plans are often simpler but similar to the plans
written in the comprehensive waiver.
Question: What happens to individuals when they need more
support than the waiver can offer, either by way of particular services and/or
overall cost?
- Individuals can apply for crisis enrollment on the comprehensive
waiver. A specialized state committee examines individual requests and assessed
needs. Sometimes Medicaid state plan services can help with portions of the
problems presented.
Question: What parameters govern transition from the supports
waiver to the comprehensive waiver?
- FSL Waiver participants retain their position on the comprehensive
wait-list for potential future opportunities. Due to funding limits, at present
enrollment in the comprehensive waiver is tightly controlled.
Question: How might a person be disenrolled from the supports
waiver?
- An individual may be disenrolled from the supports waiver when the
individual: (a) request such action; (b) is incarcerated; (c) no longer has a
disability; (d) is no longer financial eligible; (e) moves out of state; (f) no
longer meets level of care; (g) is admitted to nursing facility or intermediate
care facility for the mentally retarded (ICF/MR); (h) is no longer eligible for
Medicaid; (i) refuses services; or (g) fails to cooperate.
Question: What if the individual wants to change their service
plan, or wants to change providers?
- The individual notifies his or her service coordinator that they wish
to change, select a new provider, and set a date for new provider to begin
providing services. The service coordinator works through the required
notifications and new authorizations.
Question: How is quality assurance and quality management
managed?
- The Quality Assurance System has produced a wealth of information
with a uniform state system that measures the results of both the comprehensive
and supports waivers. The system is contracted out to the Delmarva Foundation.
- The overall quality assurance approach has changed from an outcome
perspective to quality assurance with we are here to help you
theme. The entire and extensive body of work is available on the Internet at
http://www.dfmc-florida.org.
- Monitored elements have been reduced from 175 elements to 11
elements. These include five related to service process (e.g., background
screenings, documentation for billings) and six tied to outcomes (e.g., health
status, skills building).
- The implementation of policies by providers, not just having them,
has been a key Florida discovery. The providers meet the extensive FSL Waiver
handbook at 85-90 percent level but the quality assurance efforts stress a
focus on the person and their outcomes.
- The Quality Assurance/Quality Management System for the FSL Waiver is
the same as the comprehensive waiver. It is also the same provider network with
95-98 percent of the service providers the same. Next year the quality
assurance system will differentiate between the FLS Waiver and the
comprehensive waiver.
Question: How are complaints resolved?
- Individuals can file a complaint through a Fair Hearing
process that is used to appeal a decision made by the state, or through a
grievance available through the recipients chosen support and service
providers.
- Where a grievance procedure is used, the grievant identified their
grievance and proposed resolution. The provider responds to the grievance, this
response can be appealed to the governing body. Grievance logs are examined by
the state and must be maintained by providers.
Question: What is the process that is used to monitor the
health and well-being of individuals participating in the supports waiver?
- The process used includes service coordination consultation, on site
consultation, desk reviews, and follow consultations.
- On-site monitoring is performed a minimum of every six months.
- A primary difference between the approach to supports waiver
monitoring and comprehensive waiver monitoring is that the comprehensive waiver
requires monthly face-to-face visits.
- Service coordination follows up to resolve problems revealed by
monitoring. Area offices track incidents and share them with quality assurance.
Opinions on Waiver Operations and Effects
Access to the Waiver
Explanation: Access refers to how easily people can apply for
and gain admission to the supports waiver.
- Potential enrollees learn about this supports waiver program from
current consumers, conferences, family care councils, printed matter and the
website. Funding also shapes how people learn about the FSL Waiver. Many people
are referred to the APD website for information. In the current year when new
dollars for enrollment are very limited, some complain that people have been
discouraged from applying for the consolidated waiting list.
- The supports waiver is not aggressively publicized. Word of mouth is
probably the most common way families and individuals learn about this
opportunity.
- It is Very Easy to apply. The demand for this FSL Waiver
among people is increasing steadily. Personal documentation for some, however,
may be difficult to provide. Cultural diversity issues in some locations in
Florida make it harder to get and use services.
Service Planning
Explanation: Service planning refers to the process to develop
individual support plans for waiver recipients.
- Some informants indicate individuals somewhat leads the
planning process
- However, the state officials indicate that the FLS Waiver very
much permits recipients to define their own service needs, and choose the
agencies or support givers to offer the needed support.
- Informants note that the recipients somewhat exercise
choice and control over service plans but this is shaped by the community they
live in, provider issues that may limit it, sometimes parental control, and
depends on the support coordinator. Others suggest that the supports waiver is
inherently limited in choice because it does not offer as many services or
dollars as the comprehensive waiver. Many indicated that they would like to see
more services, no caps, and more flexibility for families and individuals.
- State staff feels that service planners get to know the individuals
they are planning for Very Well while others would not go so far.
- Most agree that there are some very good support coordinators who
know the individual and families well. Yet, there is a high turnover and some
may be new and developing the necessary skill set. The state has tightened up
qualifications and is examining competency-based certification and instruction
for support coordinators.
Question: What if the individual wants to change their service
plan, or wants to change providers?
- It is very easy is it for individuals to change service providers and
this generally can be accomplished within days.
- Waiver participants cannot generally hire and manage their own
support workers. While the workers are employed by an agency, participants
often identify and refer potential workers to the agency and manage them on a
day to day basis.
- Where in-home supports are offered to adults living home
with family, the services are seen by the state as most often person directed;
some feel that it depends on the individual and family.
- The services available through these waivers are generally broad
enough to meet participant needs for individuals who do not have high needs or
need to live in a group home.
- Informants indicate that it is Somewhat Easy for
individuals to change their service plans. Regional offices can deal with
emergency situations.
Service Delivery and Safeguards
Explanation: Service delivery and safeguards refers to the
services that individuals received and their operations, and the safeguards in
place to assure health and well-being.
- Once services are authorized, informants indicate that it is neither
Easy nor Hard for individuals to get these services.
Satisfaction with Outcomes
- Generally, informants indicate that recipients are not living on
their own or with friends, but are participating in community events.
- Informants indicate that there is Some emphasis on
services to promote community integration versus services that are more
traditional (sheltered work, enclaves, segregated activities
). Many
individuals, however, use segregated services.
- Employment outcomes have been increasing from a 2,428 person baseline
in 2004 to 4,441 people maintaining employment in 2006 with the five-year
target of 5,842 people maintaining employment by 2009.
- To assure the health and well-being of participants, the safeguards
in place are generally thought to be working well.
Key Issues in Play
Question: What are the waivers greatest strengths?
- A major strength of the FLS Waiver is the ability to serve a large
number of services recipients at a predictable cost.
- Generally, many people report being satisfied with services and
report being very happy.
- Governor Jeb Bush has invested significant sums in making waiver
options available.
- The privately contracted quality assurance project is effective in
documenting system change through statewide efforts.
- Many Florida applicants have come off the waiting list and are now
receiving services.
Question: What are the barriers to achieving the waivers
goals?
- Workforce issues. Workers cannot be found easily and there is concern
over what they are paid and the associated benefits.
- Some see shortcomings as difficulties in accessing professional
therapies in some communities and the time it takes to get service
authorizations approved.
- Many people, families and individuals, report a desire for increased
self-determination with more choices and control over their chosen services,
units, and activities.
- People are being taken off the waiting list but the list continues.
- Restrictions require the individual to leave the family home if they
need a lot of care. Sometimes this seems neither less costly nor better for the
individual.
Question: Are there topics where there is disagreement or
concern?
- There is pressure to both add services and dollars to existing plans
and also to take people off of the waiting list.
- The state has worked hard to get the supports waiver up and running
and continues to seek refinements in practice as it gains experience.
- Like most states the individual (independent) Medicaid certified
providers who are direct support workers look at the person served and their
families as the employer of record. This creates problems in liability,
workmens compensation, routine paying of Federal Insurance and
Compensation Act and other taxes that can create trouble for the employer in
some situations.
Question: What are the TOP THREE things that could be done to
improve the waiver?
- Increase flexibility. Allow people to use more of the funds for needs
during the year (parallel funding for horizontal needs).
- Add a self-directed service option. In some cases people do not know
how to use the services and supports.
- Remove cap limits on spending when a person needs more services to
stay in their family home. Currently if they need nursing, therapies, or
extensive care they have to leave their family home and join the comprehensive
waiver. Some say that this is not always optimal for care or cost. Others feel
like the cap should be flexible in some situations and that expenditures should
be more in some individual situations.
- Add funds to adjust current plans and eliminate the waiting list.
- Many felt that the FSL Waiver should be expanded to include all or
most of the services on the comprehensive waiver although it would need to have
the same annual cap. Others suggest adding speech therapy, durable medical
equipment, therapy for adults, and/or all the services in the comprehensive
waiver.
- Find a way to enable environmental one time costs that hit once in a
persons plan but wipes out most of their dollars for the entire year.
Question: What other points should be raised?
- Many parents, appreciative of the supports waiver, continue to desire
additional service choices and sometimes more services overall.
- The need to eliminate any soft caps for services within the FSL
Waiver and add supports for children, including needed behavioral supports.
Overall Impressions
All informants agree that the supports waiver is generally a positive
development though early in its development. It has been effective at helping
to reduce the wait-list and contain costs within a predictable budget. Still,
many suggest that:
- The comprehensive waiver needs to continue to be available for those
that cap out of the supports waiver.
- More service options might be added to this waiver to better tailor
services and supports to needs.
- Many want more flexibility in the services and an increase in the
range of choices that individuals and families could use.
Florida provides an excellent example of what can be done, in a relative
short time, with what is already the second largest support waiver in the
United States.
Introduction
The Missouri Community Supports Waiver (CSW) for people with
developmental disabilities was launched in 2003. Missouri built on its
experience in furnishing state-funded, family-centered services in designing
this waiver to underwrite alternatives to residential services. The
waivers major aim is to reduce the waiting list through the delivery of
lower-cost services.
Method
In August and September 2006, HSRI talked with key Missouri informants
to obtain more in-depth information concerning CSW. Informants included: (a)
Division of Mental Retardation and Developmental Disabilities staff, including
the Division director and senior program managers; (b) the director of the
Missouri Planning Council for Developmental Disabilities; and, (c) personnel at
the Institute for Human Development at the University of Missouri-Kansas City,
the Missouri University Centers for Excellence in Developmental Disabilities.
The Institute works extensively with individuals and families throughout the
state.
Results
What follows are results from the key informant consultations. First,
information is presented to describe the policy goals of the waiver,
information on any service wait-lists, and the fundamental operations of the
waiver. Second, opinions offered by the discussion participants are offered
related to: (a) access to the waiver; (b) waiver operations, service planning,
service delivery and safeguards; (c) outcomes; and (d) key issues in play.
Missouri Policy Goals
Question: What are the major policy goals of the supports
waivers and how successful have the waivers been in meeting them?
- CSW was designed to serve as a low-cost alternative to the
comprehensive waiver and as a vehicle to reduce the waiting list. CSW was not
launched in response to a lawsuit.
- The CSW has been successful in relieving pressure on the mental
retardation and other developmental disabilities (MR/DD) Comprehensive Waiver.
Still, the overall number of people waiting for services continues to grow.
- Implementing self-direction direction and person-centered planning
are seen as secondary goals. Presently, there is limited use of waiver
self-direction opportunities.
- Rebalancing the long-term care system was not a policy goal. CSW
permitted Missouri to refinance some state-funded community services in order
to finance system expansion.
Wait-lists
Question: How many people are on the consolidated (i.e., all
wait-lists for developmental disabilities services) wait-list?
|
CSW |
Comprehensive Waiver
|
2005 |
3,246 |
441 |
2004 |
446 |
1,540 |
2003 |
256 |
1,180 |
Question: How are wait-lists maintained?
- Missouri maintains a statewide waiting list. State service
coordinators maintain the waiting list and track the status of individuals on
the waiting lists. (Missouri maintains two statewide waiting lists, one for
residential services and one for in-home services). However, some of the people
on these lists are not Medicaid-eligible and others are eligible for Missouri
Division of MR/DD Services but do not qualify for ICF/MR level of care. That
is, eligibility for a waiver has not been determined for all individuals on
these lists. Further, individuals may be added to the residential waiting list
for planning purposes.
- Missouri uses a scored instrument to assess the urgency of need of
people on the waiting list.
Question: How long generally is the wait?
- The average wait time is more than two years.
Basic Operations
Question: How are people selected for enrollment?
- People are selected for services by a utilization review (UR)
committee based on waiting list score. Available funds are prioritized to
support people who are experiencing an emergency or crisis.
Question: Is there descriptive information available on the
people served in the supports waiver (e.g., age, primary disability, living
arrangement, functional status, caregivers)? Is systematic information
available regarding waiver impacts?
- There is no systematic information about the impact of the CSW on
participants. By report, many people informally report that they are very happy
with services and this result has been so common that more formal measures have
not been used.
- Centers for Medicare & Medicaid Services (CMS) waiver reviews
serve as the formal evaluations of the supports waiver.
- Missouri officials indicate that they know whether the waiver is
effective by reviewing its impact on the waiting lists and by examining costs
and reported satisfaction.
Question: How are individual service plans developed?
- State service coordinators meet with the person and their family or
representative/legal guardian to complete a person-centered plan.
Person-centered planning guidelines are posted on the state website.
- When the service plan is developed, a draft budget is also created
that then goes to the UR committee. The committee considers the individual
needs in the plan, any alternative means of meeting the needs, and the amount
of service other individuals with similar needs receive in approving budgets.
Question: How are individual allocations set?
- The planning process identifies needs. A budget is drafted to meet
the needs. The budget and plan are reviewed by the UR committee when it is the
individuals first plan/budget and when there is a request to increase
supports. The individual does have general knowledge of the allocation before
planning if the person had a plan the previous year.
- Missouri does not have a budget allocation tool. Individuals receive
a copy of their approved budget annually.
Question: What decision-making authority do
individuals/families have over the budget?
- Individuals and families have input in the planning process where
needs are identified and how the needs can best be met are proposed. The budget
is developed. All new budgets or requests for increases in a budget must go
through UR.
Question: Who has primary responsibility for developing
the service plan?
- State employee service coordinators located at Regional Centers have
primary responsibility; some SB-40 County Boards also employ service
coordinators. Missouri uses targeted case management to finance service
coordination. Service coordinators facilitate the planning process with the
consumer and legal representative and others they request to participate.
- Each service coordinators supports 50 individuals on average. Service
coordinators support a range of 40-70 individuals. Case loads have been growing
due to budget limits.
Question: Does the service planning include a distinct risk
assessment process to identify and address identified risk?
- Negotiated risk agreements are not used.
- The new service planning process in the renewal for both the support
and comprehensive waivers provides for risk assessment for people who
self-direct their services. The state also is using the Health Inventory
Screening tool. Nurses ensure that health needs are addressed in the plan.
There is a registered nurse in each region and this has worked well.
Question: Is the process the same or different from that used
in the comprehensive waiver?
- The planning process is the same as that used in the comprehensive
waiver.
- Individuals usually do not utilize paid outside assistance to help
design the service plan. Community Specialists (waiver service) can assist in
facilitating the development of the plan when an independent facilitator is
requested.
Question: What happens to individuals when they need more
support than the waiver can offer, either by way of particular services and/or
overall cost?
- Service coordinators may authorize additional services. Regional
directors are empowered to respond to emergencies in individual circumstances.
Exceptions may be granted based on need. If the increased need is long-term,
the person may be transferred to the Comprehensive waiver. In the renewal, the
CSW cap was increased to $22,000.
Question: What parameters govern transition from the supports
waiver to the comprehensive waiver?
- In the last year, only 14 people moved from the CSW to the
Comprehensive Waiver. People transition to the comprehensive waiver due
emergencies and crises.
Question: What if the individual wants to change their service
plan, or wants to change providers?
- The process that an individual must follow to change service
providers includes notifying the service coordinator and over the course of 2-6
weeks the service plan is changed.
- The time it takes to change providers varies from days to months or
more.
Question: How is quality assurance and quality management
managed?
- The principle features of the waivers Quality Assurance/Quality
Management System include case management, statewide UR committee, and quality
management committee. The Quality Assurance/Quality Management System for the
supports waiver is the same as the comprehensive waiver. A score card system
has been developed. This area is seen by some as not as open and transparent or
designed for sharing as it could be.
Question: How are complaints resolved?
- The process that an individual must follow to file a complaint
includes a Department telephone hot line (800-364-9687). Also, the state has
consolidated its complaint processes and pulled investigations and consumer
complaints into one unit. Investigators who live in local areas around the
state have been consolidated into a pool. The system is able to investigate
abuse and neglect but additional investigators are needed.
- It is generally thought that the community safety and health record
is good but the state has shared only limited information about abuse and
neglect. Most provider types are licensed or certified by the state or
nationally accredited. Training has helped regional centers better monitor
fiscal matters. Service coordinators and local quality assurance staff
throughout the state often play a key role in resolving complaints that are not
considered abuse and neglect.
- The Task Force also has called for a toll-free phone number for
reporting suspected abuse and for the public to have access to completed
investigative reports as long as patients protected health information is
not revealed.
Question: What is the process that is used to monitor the
health and well-being of individuals participating in the supports waiver?
- The process includes service coordination and the quality assurance
team. Monitoring is performed at least quarterly in CSW. In the Comprehensive
waiver, service coordinators conduct monthly face-to-face monitoring for
persons who receive residential (placement) services.
- One recent development is the emergence of self advocates and
families excellence volunteer visits to homes. The state is recruiting
volunteers.
- If there is a problem, service coordinators take immediate action.
These situations are also reported to service coordinator supervisors and the
Regional Center quality assurance team.
Opinions on Waiver Operations and Effects
Access to the Waiver
Explanation: Access refers to how easily people can apply for
and gain admission to the supports waiver.
- The potential enrollees/families learn about this supports waiver
program from service coordinators and other Regional Center or SB-40 County
Board staff, with brochures and the new Network of Care website. Regional
Center service coordinators perform intake and also explain services that are
available.
- The supports waiver is somewhat publicized and individuals apply for
services, qualify for the supports waiver waiting list, and are then enrolled
by regional center service coordinators when openings become available through
attrition or new funding.
- It is somewhat easy to apply for services but the demand for this
waiver is growing quickly. Enrollment is dependent on identifying needs during
the planning process and the scoring of the need through the UR process. The
score determines the priority of the individuals need in comparison with
others who have needs.
Service Planning
Explanation: Service planning refers to the process to develop
individual support plans for waiver recipients.
- Overall, respondents indicated that the planning process
somewhat encourages individuals to exercise leadership, define
their own service needs, and choose the agencies or support givers to offer the
needed support.
- Overall, respondents indicated that recipients exercise some choice
and control over service plans but this varies somewhat by region and
participants may not have funds to secure the supports that they want.
- Overall, respondents indicated that service planners
somewhat know the individuals they plan for. Problems arise due of
staff turnover and case load variations that is caused, in part, by rotating
service coordinators.
- The waiver renewal provides for a supports broker to assist
individuals who self-direct services. It is now possible to hire independent
facilitator.
- A Missouri company currently operates fiscal intermediary services
and is able to respond quickly to timesheets and payroll responsibilities.
- The services available through CSW are generally broad enough to meet
participant needs. The waiver is written adequately but implementation of the
waiver is a challenge. Personal assistance varies a lot in the plans and there
are frequent modifications.
- Overall, respondents indicated that it is somewhat easy
for clients to change their service plans with variations among the different
state regional centers.
- The strengths of the approach to individual planning are its ability
to allow people to choose services and leave the waiting list.
- Some see shortcomings as difficulties in finding a more uniform
experience in all of the regional centers for support waiver recipients.
Service Delivery and Safeguards
Explanation: Service delivery and safeguards refers to the
services that individuals received and their operations, and the safeguards in
place to assure health and well-being.
- Once services are authorized, respondents generally indicated that it
is somewhat easy for individuals to secure services. Some rural
areas present more difficulty but generally support waiver services are
reasonably available.
Satisfaction with Outcomes
- Generally people do not seek/acquire/hold integrated employment but
are quick to use segregated day habilitation. This is an aspect that the state
is trying to change.
- Generally people do not live on their own or with friends and
sometimes participate in community events.
- There is some emphasis in the waiver to stress services that promote
community integration over services that more traditionally offer segregated
options (e.g., sheltered work, enclaves, and other segregated activities).
However, many participants are quick to use the segregated services.
- Waiver participants can hire and manage their own support workers.
The addition of support brokers in the CSW renewal will help recipients manage
workers on a day to day basis. About 200 individuals are managing their
workers.
- Liability issues pertaining to these workers persist, as they do
elsewhere. For instance, workers are not offered workers compensation.
- Fiscal intermediary support is adequate. This activity has been
expanded in the newly renewed CSW.
- Where in-home supports are offered to adults living at
home with family, the services are seen as most often as family directed rather
than person directed. Family members probably manage the activities and workers
70 percent of the time.
- To assure the health and well-being of participants, the safeguards
in place are generally thought to work well and families are helping to ensure
the health and welfare of the waiver recipients.
- The more people in their lives who care for them the safer
individuals are. Service coordination can often work well. But smaller service
coordination case loads and more caring people in participants lives
would be an improvement.
Key Issues in Play
Question: What are the waivers greatest strengths?
- A major strength of the CSW is its ability to serve more people at a
lower-cost and take the pressure off the Comprehensive Waiver.
- The waiver renewal has added support broker and has additional waiver
opportunities to help more people in the next couple years.
- The legislature has been more willing to listen to people and
political direction may be changing.
- People have more hope of getting off the waiting list and receiving
services.
Question: What are the barriers to achieving the waivers
goals?
- More flexibility is needed to better customize services and supports.
Self-direction needs to be enhanced so that participants are not stuck with
provider-managed model of supports.
- State leadership has turned over with three directors in three years.
- Achieving greater uniformity in recipient experiences at the 11
regional centers.
- Continued high growth in people seeking services.
Question: Are there topics where there is disagreement or
concern?
- There should be more residential choices and more done to promote
community employment.
- More funding is needed to meet the demand for support waiver
services.
- The current prior authorization method sometimes interferes with
structuring services to meet participant needs.
- Community providers are at capacity in some areas of the state. There
is a need for more behavioral support with increased funding to meet the needs
of some individuals adequately.
Question: What are the TOP THREE things that could be done to
improve the waiver?
- Expand use of the newly added support broker service. This new
service offers the potential of creating a renaissance in support efforts in
Missouri.
- Supported employment rates need to be increased.
- Add funds to reduce the CSW waiting list.
Question: What other points should be raised?
- Increased self-direction currently translates into more work for
regional center staff. This may explain why relatively small numbers of
families and individuals have used this feature.
- The natural support networks are as critical as anything.
Overall Impressions
All informants agree that the implementing the supports waiver has been
a positive development in Missouri. The CSW has helped people stay at home and
secure respite or other needed supports within the overall waiver cap.
A key change was shifting to an annual individual cap versus applying
caps to each service. In addition, the state has means for managing
extraordinary requests or exceptions. State staff feel that such
flexibility is essential to the successful implementation of support waivers.
Many feel too that additional improvements are possible because as a
result of changes that were made in the CSW renewal. The changes concerned
quality management, increased consumer choice, possibilities for
self-direction, and the new support broker services.
Informants, however, pointed out that there is still much to do. The
state lacks sufficient infrastructure, including technology for managing
information, to make the supports waiver work as well as it might.
Introduction
Oklahoma presently operates two In-Home Supports Waivers, one for adults
and one for children. These two support waivers are currently being used by
over 1,800 children and adults (who use 76 percent of the support waiver
capacity) in Oklahoma.
Method
In August, September and October 2006, HSRI talked with people within
and outside the Oklahoma system. These included: (a) state staff associated
with the Developmental Disabilities Services Division, including the state
director and others; and (b) representatives from interests outside the state
agency including the state association of providers, the Developmental
Disabilities Council, and the Center for Leadership and Learning at the
University of Oklahoma.
Results
The results of the key informant conversations follow. First,
information is presented to describe the policy goals of the waivers,
information on any service wait-lists, and the fundamental operations of the
waivers. Second, opinions offered by the consultation participants are offered
related to: (a) access to the waiver; (b) waiver operations such as budget
allocations, service planning, service delivery, and safeguards; (c) outcomes;
and (d) key issues in play.
Oklahoma Policy Goals
Question: What are the major policy goals of the supports
waivers and how successful have the waivers been in meeting them?
- Cost containment and related budget goals were a major policy goal of
both In-Home Supports waivers in Oklahoma. Since 1999, both waivers have
applied caps in spending per person to contain costs make waiver services
available to more people than the comprehensive waiver could accomplish alone.
- Reducing the wait-list was also a major policy goal. At one time the
wait for enrollment in the states comprehensive services waiver had
reached ten years, and the supports waiver presented significant opportunity to
address this issue. The In-Home Supports Adult and Children Waivers help keep
the number of people waiting and the length of time waiting much smaller than
in the past. Presently, the current waiting for services is no longer than
three years.
- Consumer-direction and person-centered planning goals are seen as
less primary goals of the supports waiver. State officials note, however, that
they will apply with CMS to change the supports waiver within the next 12
months during the renewal process with CMS to include self-direction
opportunities to the waivers.
- Rebalancing the long-term care system and refinancing community
services are not policy goals.
Wait-lists
Question: How many people are on the consolidated (i.e., all
wait-lists for developmental disabilities services) wait-list?
- In recent years as much as 75 percent of new dollars for the In-Home
Supports Waivers were used by existing service users for their plans.
- Wait-list figures are illustrated in the accompanying table:
2006 |
3,074 |
2005 |
3,853 |
2004 |
4,081 |
2003 |
3,494 |
Question: How are wait-lists maintained?
- Oklahoma maintains a statewide wait-list. Intake case managers
maintain waiting lists and track the status of people who apply for waiver
services but for whom slots are not available.
- The state observes a woodwork effect whereby when new
funding dollars became available many new people who were not previously known
seek waiver services. Referrals to other service systems to meet needs are
often made.
Question: How long generally is the wait?
- Presently, the average time on the waiting or interest list before an
individual is enrolled is more than two years but no one has been waiting for
more than three years.
Basic Operations
Question: How are people selected for enrollment?
- People are selected for enrollment based on the order of requests for
services, though emergency cases have priority. These emergency circumstances
include people: (a) who no longer are able to care for themselves; or (b)
individuals with caregivers who themselves are hospitalized, placed in nursing
homes, permanently incapacitated or have died. Some individuals periodically
utilize Family Support Subsidy state funds.
Question: Is there descriptive information available on the
people served in the supports waiver (e.g., age, primary disability, living
arrangement, functional status, caregivers)? Is systematic information
available regarding waiver impacts?
- There is descriptive information concerning the supports waivers
participants. Additionally, an annual report and related brochures broadly
describe profiles of participants.
- Oklahoma conducts satisfaction analysis annually of the support
waivers.
- There is systematic information available about the impact of the
supports waiver on participant costs with some limitations.
- The state has the capability to sort results by waiver but it is
currently difficult. The state is making needed changes to improve its capacity
to sort information by waiver.
- The CMS reviews and Quality Assurance surveys are the current formal
evaluations of the supports waiver.
Question: How are individual service plans developed?
- State case managers meet with the person and their family or
representative/legal guardian to complete need assessments; identify supports
needed and include others as-needed to develop plan individual service plans.
Question: How are individual allocations set?
- The full annual cap of $12,828 dollars a year for children and
$19,225 for adults is available to the recipient as long as they stay at or
under the cap. These caps are increased based on service rate increases.
Increases in the cap are possible if circumstances warrant and justification is
provided and accepted.
- The individual does have knowledge of the allocation before planning.
Question: What decision-making authority do
individuals/families have over the budget?
- Individuals with disabilities and their families plan within a
capitated dollar limit and determine services and supports needed.
Question: Who has primary responsibility for developing
the service plan?
- State case managers.
- Among the service planners the average caseload is 29 individuals per
service planner in a year.
- The case load range the average service planner during this period is
from 14 to 55 individuals per planner.
- In Oklahoma people do not have paid outside assistance available to
them during the planning process to help design the service plan?
Question: Does the service planning include a distinct risk
assessment process to identify and address identified risk?
- Negotiated risk agreements are not used.
Question: Is the process the same or different from that used
in the comprehensive waiver?
- The comprehensive waiver uses a more detailed Individual Planning
process. In the supports waiver, family members are often relied on to lead the
process and address various risk factors. As a result, the planning is
generally not as detailed or intrusive as that required when traditional
community services are used.
Question: What happens to individuals when they need more
support than the waiver can offer, either by way of particular services and/or
overall cost?
- Case managers identify other alternatives when available. If none are
available or identified, exceptions to increasing the cap can be approved and
entry to the comprehensive waiver can be offered when slots are available. So
far Oklahoma has been able to accommodate individuals as-needed in its
comprehensive waiver.
Question: What parameters govern transition from the supports
waiver to the comprehensive waiver?
- People may move to the comprehensive waiver when their critical
support needs no longer can be met with the supports waiver, non-waiver
services, or other resources as determined by the Developmental Disability
Services Division (DDSD) Director or designee and funding is available.
Question: What if the individual wants to change their service
plan, or wants to change providers?
- The individual notifies his or her case manager that they wish to
change, select a new provider, and set date for new provider to begin providing
services. The case manager works through the required notifications and new
authorizations.
Question: How is quality assurance and quality management
managed?
- The Quality Assurance/Quality Management System for the supports
waiver is the same as the comprehensive waiver.
- The principle features of the waivers quality assurance and
quality management system include: (a) case management; (b) various surveys and
reviews (i.e., consumer satisfaction surveys, provider performance surveys,
critical incident reviews, medication event review, retrospective audit
reviews); and (c) uses of oversight committees (i.e., statewide behavioral
review committee, human rights committee, quality management committee).
- The states Office of Client Advocacy (OCA) approves community
provider grievance policies and procedures.
Question: How are complaints resolved?
- Individuals may file complaints by pursuing:
- A Fair Hearing process to appeal a decision made by the
Department. Complainants (and/or their representatives and witnesses) and
Department representatives present their case. A Hearing Officer issues a
written decision that can be appealed to the Director of Human Services, the
Directors written decision can be appealed in District Court.
- A grievance process through the OCA whereby local offices and
providers retain grievance coordinators who assist recipients with
the process. Complainants (and/or their representatives and witnesses)
identifies their grievance and a proposed resolution. A local official responds
to the grievance, this response can be appealed to the governing body, if not
resolved there, the grievance moves to an independent administrative committee.
- An administrative inquiry that can be initiated by calling,
writing, or emailing the state Quality Assurance office with a complaint
related to provider performance. After receiving a complaint, this office
completes an investigation and issues findings which may include provider
citations.
Question: What is the process that is used to monitor the
health and well-being of individuals participating in the supports waiver?
- The process includes a mix of preventative activities (i.e., provider
training, provider background and abuse registry checks, pre-employment
screenings), on-going monitoring (i.e., case management, provider monitoring,
critical incident reporting), and look-behind review through consumer
satisfaction surveys.
- Systematic monitoring of individual well-being is performed a minimum
of every six months.
- When issues are uncovered, case managers are charged with following
up and seeking resolution.
- A key difference the supports and comprehensive waiver is that the
comprehensive waiver requires monthly face-to-face visits by case managers. For
those in residential services, it also includes completion of the Physical
Status Review (PSR) by the case manager and monitoring by DDSD registered
nurses in accordance with the Health Care Level identified on the PSR.
Opinions on Waiver Operations and Effects
Access to the Waiver
Explanation: Access refers to how easily people can apply for
and gain admission to the supports waiver.
- Some indicated that applicants and families must work hard to find
out about services and that the new website is still difficult to navigate.
- Informants noted that the supports waiver is only
somewhat publicized. Families learn about this supports waiver
through brochures and word of mouth. In addition, applicants can learn about
and apply for the program by contacting area office intake staff via telephone,
mail, or through the Internet. Referrals may also come from staff of other
service agencies, including from the statewide referral services, Outcome and
Assessment Information Set.
- Informants indicated that it is neither easy nor
hard to apply, and that individual experiences vary.
- Informants noted the demand for this waiver among people is
increasing somewhat.
Service Planning
Explanation: Service planning refers to the process to develop
individual support plans for waiver recipients.
- Overall, the planning process encourages individual to somewhat lead
the planning process and somewhat define their own service needs. Families in
some cases just need to be better informed and some say the state errs on the
conservative side, so that participants do not always see the flexibility they
seek in the program. Others note that the system is evolving and that in ten
years that participants and families will be leading the planning process more.
- Overall, the planning process Very Much encourages
individuals to choose the agencies or support givers to offer the needed
support.
- Recipients do exercise choice and control over service plans, but may
not have funds for all of the choices they make.
- Service planners Somewhat know the individuals they are
planning for because of turnover in staff and case load variations.
- There is no supports broker or personal agent to assist individuals
to put together the plan and/or negotiate services for the individual.
- It is very easy is it for clients to change their service plans.
Informants note that it is a common occurrence.
- The strengths of the approach to individual planning are its ability
to allow people to choose services and leave the waiting list.
Service Delivery and Safeguards
Explanation: Service delivery and safeguards refers to the
services that individuals received and their operations, and the safeguards in
place to assure health and well-being.
- Once services are authorized, it is neither Easy nor
Hard for individuals to get these services. It can vary by
location, given geographic differences, but generally the system responds well.
For instance, some note that it can be difficult to get professional therapies
in some communities.
- The services available through these waivers are generally broad
enough to meet participant needs.
- Some informants feel that the release of service authorization
numbers can be managed more promptly to reduce the time between
authorization and actual service delivery.
- Informants note that it is Very Easy for individuals to
change service providers. This generally takes a few days, up to 30 days.
- Waiver recipients cannot generally hire and manage their own support
workers. Workers are typically employed by an agency. Recipients, however,
often identify and refer potential workers to an agency and subsequently manage
them day to day.
- There is Some emphasis on promoting community integration
versus services that are more traditional (sheltered work, enclaves, segregated
activities
). Many recipients, however, use segregated services.
- There is a pilot for a small group of 17 IHSW service recipients
whereby they utilize a fiscal agent. Except for this pilot group, there is not
a fiscal intermediary or payroll service available to help the individual
control or manage the amount allocated for his or her services.
- To assure the health and well-being of participants, the safeguards
in place are generally thought to be working well. Family members help assure
the health and welfare of the waiver recipients.
- Where in-home supports are offered to adults living home
with family, services are seen by the state as most often person directed.
Others feel, however, that it depends on the individual and family and that it
is instead often family directed.
Satisfaction with Outcomes
- Generally, many people report being satisfied with services and
report being very happy.
- These waivers make services available that effectively support
individuals to.
- Generally seek/acquire/hold integrated employment.
- Generally live with family, on their own or with friends.
- Generally participate in community events.
- It is thought that recipients are basically safe and there is a good
fit of supports.
Key Issues in Play
Question: What are the waivers greatest strengths?
- To serve a large number of services recipients at a predictable cost.
- State leadership has been sustained and many believe that the state
staff members are effective advocates. These circumstances have been an
on-going strength of the system for the ten years.
- People have hope of getting off the waiting list and receiving
services.
Question: What are the barriers to achieving the waivers
goals?
- Workforce issues. Only one company was found who was willing to offer
workers compensation to direct support workers involved with the supports
waiver.
- Increased self-determination. Oklahomans believes in the power of
local personal relationships, so many note that the supports waiver, which
depends on such relationships, is a good fit for the state.
- People are being taken off the waiting list but the list continues.
Question: Are there topics where there is disagreement or
concern?
- Some suggest that to save dollars support waiver recipients are being
encouraged to room with other waiver recipients. Others argue that such
practice is not state policy.
- One significant issue pertains to the amount of money service
providers make and what amount they may retain as profit.
- Another issue pertains to the use of paid family members. To the
extent they are paid, the pattern may limit other service choices the recipient
would have had otherwise.
Question: What are the TOP THREE things that could be done to
improve the waiver?
- Add a self-directed service option.
- Add funds to adjust allow greater flexibility within current service
plans and to eliminate the waiting list.
- Some feel that the waiver is inadequate to provide even the most
basic services and is sorely under funded. In short, they feel that it amounts
to a band aid on a very large wound and argue that more resources
are needed to add new recipients and expand the service array.
- Some feel that being tied to Medicaid providers and products that can
be purchased through Medicaid adds to costs. They noted that sometimes
particular products can be purchase elsewhere (i.e., off the shelf)
from discount stores, for instance, at a lower price. They argue that such
skill and independence should be promoted. For example, a young man in a rural
part of the state should be allowed to use the affordable local gym and
exercise plan and not be forced to take the limited services of a physical
therapist who must travel hundreds of miles to serve him.
Question: What other points should be raised?
- Many participants want increased self-direction within the waiver.
While a relatively new concept, Oklahoma has some experience with the concept
through its family support system.
- There is a need for an effective advocacy group in Oklahoma. Such
groups tend to form on an issue and then disappear. The Tulsa Arc has been long
standing but some offered that there is really no enduring and effective
statewide advocacy organization.
- Transit options are available in two larger cities, but a significant
issue elsewhere.
- Adults who are out in the community have come off the
radar and are difficult to anticipate and count.
- The state has every kind of employment setting and some feel that
vocational rehabilitation is not an active enough player in promoting systems
change and community employment.
Overall Impressions
Although the supports waiver is early in its development (with a
successful CMS recent renewal), all agree that it generally has had a positive
impact. The waiver has proven to be financially predictable and as an effective
tool for addressing the wait-list. There is some disagreement, however, over
the need for dollars to fund existing plans versus the need for dollars to
reduce the wait-list further. The health and welfare of recipients has not been
a problem due to strong family ties and family supports, and other mechanisms
that the state has put into place. Most people agree though that more can be
done to promote self-direction. In response, the State plans on adding
self-direction options in July 2007.
One major expansion for 2008 or later from the principle target group
(i.e., people with mental retardation) involves the addition of people with
autism. The planned expansion would include family mentoring and behavior
analysis, use of TEACH techniques, and other methods.
Introduction
Oregons Supports Services for Adults Waiver (SSAW) was a direct
outgrowth of the Staley et al. v. Kitzhaber lawsuit that was filed in
January 2000. The Staley litigation was filed on behalf of over 5,000
people waiting for community services. The resulting settlement required that
the state systematically address its waiting list. In doing so, the state
proceeded in ways to promote self-direction, but also needed to work within a
very difficult state budget climate. The SSAW was launched in July 2001.
Method
In August, September and October 2006, HSRI staff conducted face-to-face
discussions with key informants on-site and follow-up conversations by
telephone with additional informants. The individuals we spoke with included:
(a) state staff associated with the Office of Developmental Disability Services
Seniors and Persons with Disabilities (DDSPD), Oregon Department of Human
Services including the state DDSPD director and others; and (b) representatives
from interests outside the state agency including the Oregon Developmental
Disabilities Council, the state provider association, experienced county
program managers and managers of the support brokerages, and the Oregon
Advocacy Center.
Results
The results of the discussions with key informants follow. First,
information is presented to describe the policy goals of the waiver,
information on any service wait-lists, and the fundamental operations of the
waiver. Second, opinions offered by the consultation participants are related
to: (a) access to the waiver; (b) waiver operations such as budget allocations,
service planning, service delivery, and safeguards; (c) outcomes; and (d) key
issues in play.
Oregon Policy Goals
Question: What are the major policy goals of the supports
waivers and how successful have the waivers been in meeting them?
- Given the Staley court settlement, cost containment and budget goals
were a major policy goal. This waiver survived the Oregon state budget crisis,
though the settlement was modified. In particular, start-up actions were
scheduled to end in 2007 but were put off to 2011 with a measured entry of
1,000 people per biennium.
- As part of the Staley litigation, the wait-list became a major focus
of the supports waiver. Original goals, however, had to be modified due to the
state budget crisis of the time, though the state is making steady progress on
the wait-list.
- Consumer-direction and person-centered planning goals are
cornerstones of the Oregon support waiver approach.
- Rebalancing the long-term care system and refinancing community
services are not the primary policy goals associated with support services.
- The Staley settlement agreement in 2000 set the stage for the
successful emergence of this supports waiver, and the success of the waiver
appears to be ending the litigation.
Wait-lists
Question: How many people are on the consolidated (i.e., all
wait-lists for developmental disabilities services) wait-list?
- The following table shows the number of people waiting for services
from 2003-2006.
Adult Services
Year |
Comprehensive Waiver
|
Support
Waiver |
Total |
2006 |
2,000 |
1,500 |
3,500 |
2005 |
2,000 |
1,500 |
3,500 |
2004 |
1,000 |
2,270 |
3,270 |
2003 |
1,300 |
1,000 |
2,300 |
Question: How are wait-lists maintained?
- The wait-list along with a great deal of other support waiver
information is tracked by either the Community Developmental Disability
Programs (CDDP), the support brokerages and state as part of the Staley
settlement with careful periodic counts and Internet summary report postings.
The wait-list has been monitored for years and is thought by most people that
it will be eliminated as the roll-out of the settlement agreement is completed
over the next several years.
Question: How long generally is the wait?
- Once the phase-in is completed in 2009, an eligible person requesting
Support Services must be enrolled within 90 days. There will still be a
wait-list for comprehensive services. Previously, there was a 20-year wait.
Basic Operations
Question: How are people selected for enrollment?
- Individuals apply for services through county offices.
- During the phase-in period of the waiver, Oregon uses a well-defined
order of enrollment. First priority are those in crisis, with
crisis defined as being at risk of civil commitment or at imminent risk of
losing their homes. Next are a range of others including those with, aging
caregivers, children transitioning from with existing support plans in programs
such as family support, individuals aging out of educational
system, and other wait-listed individuals. Enrollment is carefully analyzed to
provide trend information as to the categories of individuals enrolling into
support services. Waiting list rules are extensive and readily available.
Question: Is there descriptive information available on the
people served in the supports waiver (e.g., age, primary disability, living
arrangement, functional status, caregivers)? Is systematic information
available regarding waiver impacts?
- Oregon conducts consumer satisfaction evaluations annually with all
participants, includes questions regarding improvement in quality of life and
identifies those improvements.
- The CMS reviews, consumer satisfaction surveys, and quality assurance
surveys are the current formal evaluations of the supports waiver. The state
relies on the involvement of parents and families.
- The state is also conducting reviews of the service brokerages in a
manner that follows the CMS Quality Framework. Some brokerage directors,
however, comment that some of the most innovative and imaginative support plans
are not captured by the routine application of the framework.
- Oregon staff members indicate that they understand whether the waiver
is effective especially in areas such as costs and reported satisfaction with
services.
Question: How are individual service plans developed?
- County case management has a limited role. Counties perform
eligibility reviews, approve the individual plan for Medicaid compliance,
provide protective services, assist in crisis management, and bill under
Medicaid administration.
- Oregon has established a network of independent support service
brokerages throughout the state. Brokerages were selected by a
competitive request for proposal process. Parents cannot be brokers to their
own children.
- Support brokers called Personal Agents meet with individuals and
their family or representative/legal guardian to develop a plan based on needs.
The Personal Agent works with the individual to complete a customer goal
survey. This survey guides the collection of information related to the
individuals available and needed supports as well as health and safety
concerns in a variety of areas. Based on the customer goal survey a plan of
support is developed.
Question: How are individual allocations set?
- Allocations per person are capped according to several benefit
levels. The basic funding available to a Medicaid Waiver recipient is $9,600
per year. If the individuals needs are significant, as measured by a
standardized tool (Basic Supplement Criteria Inventory or BSCI), that amount my
increase. A score of 60-80 on the BSCI allows access to $14,400 per year while
a score of 81 or greater allows access to funding up to $19,999 annually for
Medicaid waiver recipients. Non-Medicaid Waiver recipients receive a base
benefit rate of $3,840 or $5,760 or $8,000 per year depending on the needs as
assessed using the BSCI.
- Individuals, along with Personal Agents and members of the
individuals chosen circle of support identify supports needed and goals.
They then develop an individual support plan (ISP) to address needs.
- Oregon has a 76 page handbook entitled Rate Setting and Purchase
of Self Directed Support Services from State Licensed or Certified Providers
Organizations that explains what can and cannot be purchased with support
waiver funds. This guides the provider to reasonable and customary charges.
This and the extensive, over 94 pages of rules that the state developed, have
helped Oregon manage the Support Services for Adults.
- The State of Oregon has developed and made available a set of
Expenditure Guidelines that explains to Personal Agents what can and cannot be
purchased with support waiver funds. Additionally, a Rate Guidelines exists
that sets reasonable and customary rates for services.
- Emergency crisis services are available and have in the current year
been used more than anticipated.
- The individual has knowledge of the allocation BEFORE planning. The
planning process is not geared towards spending the allocation, but rather
identifies support needs first, then looks for ways to address those needs.
Only when other options, particularly natural supports, cannot be found are
support funds utilized.
- Individuals budget for an average of approximately $800 a month but
have actually expended an average $630 a month. Consistently about 70-80
percent of the budgeted plan dollars are spent. For a number of years this has
resulted in some dollars being returned to the state budget. Subsequently the
state has changed its budgeting methodology to more closely align with the
anticipated actual per person expenditure of plan costs.
Question: What decision-making authority do
individuals/families have over the budget?
- Individuals can plan within the benefit level for which they are
eligible and determine services and supports needed. Effort is made to change
the commonly held perception that they have a grant and use the
expenditure guidelines and training to assist individuals and families in
making a problem solving ISP.
Question: Who has primary responsibility for developing
the service plan?
- Personal agents have the primary responsibility for developing the
service plan of care. This is a service as defined in the supports waiver.
Currently there are 100 Personal Agents in Oregon employed by nine support
brokerages.
- Personal Agents help set up the plan. CDDP case managers authorize
the plan from a Medicaid perspective, but do not otherwise judge the ISP.
- Among the Personal Agents the average caseload is 40 individuals. It
started at ten when the support waiver began and with current budget plans will
end up at 45 individuals.
- The average case load range for a Personal Agent during this period
is from 38-42 with a maximum average of 45 individuals per agent.
Question: Does the service planning include a distinct risk
assessment process to identify and address identified risk?
- While there is not a formal risk assessment, the service planning
includes elements of a distinct risk assessment process to identify and address
identified risks.
- Negotiated risk agreements are not used.
Question: What happens to individuals when they need more
support than the waiver can offer, either by way of particular services and/or
overall cost?
- Brokers can look past paid Medicaid services and look out
and connect people with other public or community resources.
- If the individual is in crisis, the brokerage and CDDP
staff members work jointly to develop a plan.
- In Oregon people do not have paid outside assistance available to
them during the planning process to help design the service plan.
Question: What parameters govern transition from the supports
waiver to the comprehensive waiver?
- An individual may be disenrolled from the supports waiver if the
individual: (a) is incarcerated for a defined period of time; (b) no longer has
a disability; (c) is no longer financial eligible; (d) moves out of state; (e)
no longer meets level of care; (f) is admitted to nursing facility or ICF/MR;
(g) is no longer eligible for Medicaid; (h) refuses services; or (i) fails to
cooperate with plan development. One emerging issue is recipients who engage in
risky behavior or do not want to perform required planning activities. The
technical bias of the support waiver is not to disenroll. However, not being
eligible for the supports waiver does not exclude an individual from being
eligible for supports services. The difference is the level of benefit the
individual will be entitled to.
- Approximately 700 people have left the support service brokerages
after initial enrollment. The following table suggests common reasons for
termination including the top two reasons moving to the comprehensive waiver or
moving out of state. As shown, 38 percent of individuals who leave the supports
waiver are moved to the comprehensive waiver if no other intervention is
sufficient. The percentage of individuals refusing services has decreased
significantly from the first year of the services to the current year.
Individuals are now given more information prior to enrolling in services.
Termination Reasons |
Percent |
Refused
services |
22% |
No longer
eligible |
4% |
Moved from
area |
22% |
Moved to
Comprehensive Waiver |
38% |
Deceased |
10% |
Legal Rep
withdrew |
1% |
Health/other
issues |
0% |
Other/unknown |
3% |
Question: What if the individual wants to change their service
plan, or wants to change providers?
- The individual must contact their Personal Agent. Individuals can
terminate arrangements at will. It is very easy for individuals to change
service providers. The time it takes to do this varies.
Question: How is quality assurance and quality management
managed?
- Personal Agents work with individuals and families to develop a plan
of support where non-traditional workers may be hired. In such instances,
brokerages follow the Internal Revenue Service rules and process to become the
employer agent. Direct service workers are generally determined to
be domestic workers, but also may be bona fide independent contractors or
supplied by a licensed agency individuals and families can acquire information
on this matter by visiting the following website:
http://www.sdri-pdx.org/customers/index.html.
- Fiscal intermediary or payroll services are available to help
individuals control or manage the amount allocated for his or her services.
- State officials argue that quality assurance is not just for
individuals, but that it is important to build in safeguards to maintain
cohesion in thought and action among various system players, offer supports to
the brokerages, maintain vigilant oversight to assure that policies are
appropriate and decisions are acceptable. Staff members find that operational
policies tend to be narrow and that increased flexibility is needed over time.
- State staff conducts field reviews and file reviews to oversee
individual circumstances.
- The state uses the components of the CMS quality framework as a
reference to assess its various waivers.
- The Quality Assurance and Quality Management System for the supports
waiver differs from the comprehensive waiver. In part due to the settlement
agreement the SSAW routinely collects extensive information about recipient
outcomes and group characteristics.
- The Staley Implementation Group has created a series of benchmarks to
monitor services. Likewise, the state uses a series of personal indicators and
support indicators covering 13 pages to see what is or is not working. The
results have not been published yet as a statewide quality measure.
Question: How are complaints resolved?
- Individuals may file either an administrative complaint or a Medicaid
Fair Hearing request.
- A Fair Hearings request is processed according to the rules of
the Department of Human Services. There has been one hearing to date.
- An administrative complaint may also be filed locally with the
relevant brokerage. Here, the grievant identifies their grievance and a
proposed resolution. The matter is managed locally through a stated protocol
within the brokerages. If not resolved at the brokerage level, the complaint
may be forwarded to the CDDP level, and eventually the state level for
resolution. Any corrections are carefully spelled out with detailed written
specifications.
Question: What is the process that is used to monitor the
health and well-being of individuals participating in the supports waiver?
- Personal Agents are active in pursuing health and welfare concerns
and completing any necessary follow-up activities. Personal Agents may use a
well being assessment to help understand the circumstances of the
individual.
- Personal Agents contacts with individuals vary in frequency, based on
the needs and desires of the individual. They review the support plan from a
financial perspective quarterly to see if it is working however, these actions
do not require a face to face contact.
- There is an adequate provider pool and over five years only three
providers in Oregon have not continued support waiver services and two are not
taking new support waiver recipients. However, concerns are being raised about
the continuing adequacy of the provider pool, particularly as it relates to the
current rate structure used within support services.
- Customer monitoring of quality can vary among brokerages and may
involve personal agents use of periodic check-ins, satisfaction surveys
or post cards, and use of Quality Committees. A Quality Committee
is a group of recipients who meet to give feedback to the brokerage about how
their supports are working and to suggest ways that their supports or the help
they receive from their supports could be improved.
- A key difference between the supports waiver and comprehensive waiver
is that the comprehensive waiver requires more intense monitoring by case
managers.
Opinions on Waiver Operations and Effects
Access to the Waiver
Explanation: Access refers to how easily people can apply for
and gain admission to the supports waiver.
- The potential enrollees and their families learn about the supports
waiver with through the CDDP, printed matter, such as brochures, and related
websites.
- In addition a 20 page publication, A Roadmap To Support
Services, is available. This product, developed in cooperation by the
Oregon Advocacy Center, the Oregon Council on Developmental Disabilities, and
Oregon Department of Human Services, offers an understandable guide to the
waiver. It is available in hard copy or by Internet
http://www.ocdd.org/pdfs/Roadmap_2nd_edition.pdf.
- Respondents indicate that it is Somewhat Easy to apply
and the demand for this waiver among people is increasing. People are referred
to the support brokerage when they reach the top of the wait-list, based on
their particular enrollment category.
Service Planning
Explanation: Service planning refers to the process to develop
individual support plans for waiver recipients.
- Overall, respondents indicated that recipients Very Much
lead the planning process and define their own service needs and, choose the
agencies or support givers to offer the needed support
- Recipients do exercise a lot of choice and control over service
plans, but may not have funds for all of the choices they make.
- Overall, respondents indicate that service planners generally
Know Well the individuals they are planning for, though there are a
few exceptions. Recipients may not always want to be known well. Assuring that
planners know the people they are planning for is more of a challenge as case
loads have grown.
- Overall, respondents indicate that the services available through
this waiver are generally broad enough to meet participant needs.
- Respondents indicate that it is Very Easy for individuals
to change their service plans. About 10 percent of costs change during the life
of the ISP.
Service Delivery and Safeguards
Explanation: Service delivery and safeguards refers to the
services that individuals received and their operations, and the safeguards in
place to assure health and well-being.
- Once services are authorized, respondents indicate that it is
Somewhat Easy for individuals to receive designated services.
- A protective service statute and mandatory reporting is part of the
training for personal agents and it is working well.
Satisfaction with Outcomes
- Generally, respondents indicate that individuals do not seek, acquire
or hold integrated employment but this is a currently a point of emphasis and
promotion by the state.
- About 80 percent of support waiver recipients live with their
families.
- Generally, respondents indicate that individuals do participate in
community events.
- Respondents indicate that there is Some promotion in the
waiver to promote community integration versus services that are more
traditional (sheltered work, enclaves, segregated activities
) segregated
services.
- Waiver recipients can generally hire and manage their own support
workers. About half do.
- When in-home services are offered to adults living at
home with family, the services are Sometimes family directed and
Sometimes person-directed or both. This can be a point of friction.
Key Issues in Play
Question: What are the waivers greatest strengths?
- The waiver allows people to live at home with their families and to
self-direct their services. Many supporters of the waiver characterize it as a
remarkable adventure. Some feel that within Oregon the support
waiver is will be seen in the future as an entitlement.
- Most agree that the self determination aspect of the support waiver
is the king of the world.
- There is a feeling of shared success and ability to work through
things with the state, support brokerages, advocacy community, and various
stakeholder groups like the Staley Implementation Group. In general these
parties speak well of each other and credit each other for the level of success
Oregon has enjoyed. The support waiver roll-out survived the 2003 enrollment
freeze.
- Most (71 percent) waiver recipients report they were
Happy with the supports and services they receive. There is also an
ease within families because someone else is involved in life event planning
and in a supportive relationship with the recipient and family. Some report
more frustration and dissatisfaction as they learn and become more informed
overtime.
- The Oregon support waiver has numerous written products that are
useful. For example, the 25 page Handling Emergencies: A Guide to Personal
Safety & Emergency Management that came out in September 2006 is
concise, understandable, and cogent. This is typical of 20 other written
documents that have emerged within the Oregon support waiver.
Question: What are the barriers to achieving the waivers
goals?
- Some see support waiver shortcomings as need for continued refinement
in helping people throughout the state understand how they can better use the
support waiver to make meaningful changes in their lives.
- There is a need to find financial balance between the
comprehensive and supports waivers. The supports waiver has had the same fee
structure since its beginning and it is not currently on the table for
discussion. This threatens in several ways. For instance:
- The $37, five hour a day cap on day activities may limit future
providers involvement. One provider, a college, has stopped enrolling waiver
recipients and one community provider is talking with recipients to find ones
that it is can afford to serve with that allotment.
- The ability of the system to maintain a skilled and dedicated set
of personal agents and other service workers without cost of living and other
adjustments through the years may result in an unavoidable loss of quality
services. Due to lack of funds, Personal Agents are forced to balance between
health and welfare and self determination.
Overall, the state is struggling with the cost of growing numbers
of crisis cases and the culmination of the roll-out of the Staley settlement
with only the planned appropriations.
- Some say that the state has insufficient resources for overseeing the
entire waiver system. They argue that the supports waiver has gotten a lot of
focus, but challenges also exist regarding operations of the comprehensive
waiver as well.
- Due to diminishing resources and the lack of cost-of-living
adjustments over the past several years, the providers are struggling to
maintain quality staff and facilities. Employee turnover runs at above 60
percent and providers complain about a lack of qualified applicants. Providers
suggest that Oregon must significantly increase support of community providers
or many will collapse. If the community system fails, in part or completely,
the state will be forced to find alternatives that are either substantially
more expensive, or poorer quality, or both. The Oregon Developmental
Disabilities Coalition supports the DHS Policy Option Package that would
increase funding to the system by $63 million.
- Issues have been raised pertaining to direct support workers that
individuals hire outside the traditional provider network. Issues pertaining to
employer liability regarding these workers linger. These workers
typically are not offered workers compensation or other benefits. Oregon
has had litigation where the support brokerage was determined not to be the
actual employer. One practical part of this challenge is in rural areas where
over half of the support workers are family and 80 percent are direct service
workers not employed by an agency. Oregon is unusual because direct support
workers serving seniors and people with physical disabilities became unionized
and acquired workers compensation and other benefits as a result. There
is now a Home Care Commission, but the workers are not state employees, but as
a result of a recent state initiative passed by the voters were allowed to
unionized and bargain. This resulted in a large increase in workers
compensation claims. Most feel that this employer liability is an
Achilles heel of this type of waiver that could bankrupt support
brokerages or result in successful litigation against the state.
- Some observe that operations involved with the supports waiver are
much more involved, difficult, and risky than was commonly believed at the
beginning. The need for a fiscal intermediary, for example, created a common
understanding about certain forms of risk and the need to manage
it.
- Most feel that the personal agent relationship is a pivotal piece of
the support waiver and their skill, ability, reimbursement, and training will
be critical to the continued success of the support waiver.
Question: Are there topics where there is disagreement or
concern?
- One issue of tension involves the capacity of providers to request
payment, even when circumstances result in a service not being delivered. This
issue arises when an individual agrees to receive services but for whatever
reason fails to show. The provider, as a result, may be left with expenses but
having failed to deliver the service, cannot seek reimbursement. The state took
a strong stand to refuse payment in circumstances like these. Providers
objected, arguing that they could not bear the loss of such revenue. State
officials, while pressing providers to factor in such occasional losses within
their overall business plans are relying on intelligent and cooperative problem
solving to resolve the issue. The system, however, is already stretched
fiscally and the solution may simply require more money.
- Personal Agents wrestle with growing caseloads and extensive
paperwork. One recent survey suggests that half of personal agents time
is now engaged in necessary paperwork.
- The real challenge of changing service plans often rests with the
need for CDDP reauthorization. Not all CDDPs are county based; some are
independent of the local county. Personal Agents are skillful at making needed
changes without triggering a cumbersome reauthorization process.
- Reconciling the time sheets of direct support workers can pose a
significant difficulty for fiscal intermediaries. Some report that the fiscal
agent duties are costing them more than they are paid. Some report the duties
are a helpful part of the overall support waiver economics.
- Individuals who are waiver recipients sometimes live
risky lifestyles. Brokers are taught not to ignore these but
assuring the health and well-being of such individuals is sometimes much more
difficult.
Question: What are the TOP THREE things that could be done to
improve the waiver?
- More funding is needed to improve training, raise service rates of
pay, and provide additional needed services.
- Increase the flexibility in the services that can be purchased. The
supports waiver sometimes lacks flexibility and injecting more flex would not
always cost more. Some feel that state monies are necessary to pay for services
that Medicaid cannot fund but would make a lot of sense in individual cases.
- More training for people and families to advocate for themselves.
- More structure, training, benefits for workers on supports waiver
with more agency backup.
- Better training for personal agents about services in general and the
many pieces they work with including services in general, food stamps, social
security, mental health care, and alcohol and drug treatment.
- Some voices feel that the initial roll-out could have been more
ambitious. More could have been done to identify millions of dollars were not
used in support plans and returned to the state general funds. The state has
not allowed any back fill for the vacancies that have developed. Others believe
that the state has made frugality a cherished alter goal for the
support waiver at the cost of forward movement.
- Many respondents felt that the Oregon state staff worked hard with
others in the state to fashion a supports waiver that is well thought out and
has many superior features. Respondents also indicated that they had
learned much about its operations over the past few years and have made
adjustments along the way. Participants expressed willingness to describe their
system to others elsewhere and share their experiences.
Question: What other points should be raised?
- All informants argued that there is a great need to promote supported
employment. The state launched a website promoting supported employment to
illustrate successful employees (See
http://www.dhs.state.or.us/dd/supp_emp/).
Some note that Vocational Rehabilitation staff should move more quickly to
identify when it can do no more, and allow the individual to move into the
supports waiver instead of offering services at a a glacial rate.
- Oregon has diverse geographic areas. For example, one support
brokerage covers 13 counties in Eastern Oregon and serves a geographic area
greater than the rest of the brokerages combined. In rural parts of the state
travel time can provide an economic challenge. Towns vary enormously on how
much transportation is possible and available. Almost always recipients move to
larger towns to get the supports and help they need, especially if they have
mobility impairments.
- Some say that participants are not getting sufficient training,
support and education so they can play a true self-directed role in
their services.
- One dilemma for direct service staff members who are employed as
domestic workers is that they are not paid for training time and
can only be paid for direct face to face recipient services.
- One development worth noting is the emergence of affiliated
apartments where parents may assist their son or daughter to move in with
others who are receiving supports waiver services. Three of these apartments
existed three years ago, and at least five more are in planning. These sites
can be, unintended, almost facility like because of the high concentration of
waiver recipients in one area.
- Overall there are nine brokerages. There are seven support waiver
brokerages that are stand-alone and non profits. While most are strong, one has
struggled with providing progress reports in a timely way. Brokerage capacity
can be expanded through a request for proposal process.
- Five years of policy work by the state continues to be revisited and
sometimes old decisions are changed. Generally the state receives high marks
for its forethought. Some decisions, usually revolving around funding
limitations, are seen by some as being too directed.
Overall Impressions
The Oregon SSAW has increased in enrollment to ten times what it was
when it began five years ago. It has served as an effective means for
addressing the wait-list and to do so cost effectively. More than that,
however, it has provided systematic means for the state to advance policy goals
tied to self-direction.
The waiver was built on a commitment to self-direction and has steadily
evolved to improve its associated policies, procedures, and operations. The
state has identified and kept to seven core functions of self-direction,
including: (a) assisting customers to determine their needs and plan supports;
(b) assisting customers to find and arrange resources and supports; (c)
providing education and technical assistance for customers; (d) providing
fiscal intermediary services; (e) providing customer employment administrative
support; (f) facilitating community building; and (g) assuring customer
monitoring of quality.
With time, systems have been put into place to translate these functions
into actual policy and practice. All agree, however, that in the doing that
new, often unexpected, difficulties have emerged that press the system to
redefine itself continually and reshape itself. State leaders and others often
must challenge themselves to revisit and change standing policies. Other
difficulties remain in play and defy easy solution. Issues pertaining to the
workforce, for instance are not easily resolved. Likewise, assuring quality
within a system that promotes diversification and self-direction is a
challenging task.
Still, the Support Services for Adults Waiver has proven itself with
most stakeholders and leaders in Oregon. It faces all of the challenges faced
by the other support waivers around the nation and is threatened most by the
future availability of necessary funding.
Introduction
The Pennsylvania Person and Family Direct Support (PFDS) Waiver was
launched in July 1999 to provide services that enable people with I&DD to
continue living in their own homes or with their families. This waiver was
developed in great part as a response to the states waiting list. By the
end of the current state FY, overall, the children and adults on the PFDS
Waiver total of 7,930 are expected to be enrolled in the PFDS Waiver and
another 15,340 in the comprehensive Consolidated Waiver.
Method
In August and September 2006, HSRI talked with key Pennsylvania
informants to obtain more in-depth information concerning the PFDS Waiver.
Informants included: (a) state staff in the Office of Mental Retardation (OMR),
including the Deputy Secretary for Mental Retardation and others; and (b)
representatives from interests outside the state agency including the
Developmental Disability Planning Council, Temple University, the Training
Partnership that works extensively with individuals receiving waiver services
and their families in a statewide coalition, and Pennsylvania Protection and
Advocacy.
Results
The results of the key informant conversations follow. First,
information is presented to describe the policy goals of the waiver,
information on any service wait-lists, and the fundamental operations of the
waiver. Second, informant view are summarized concerning: (a) access to the
waiver; (b) waiver operations such as budget allocations, service planning,
service delivery, and safeguards; (c) outcomes; and (d) key issues in play.
Pennsylvania Policy Goals
Question: What are the major policy goals of the supports
waivers and how successful have the waivers been in meeting them?
- While important, cost containment and budget goals are currently not
the most emphasized goals. Since 1999, individual allocations within the PFDS
Waiver have been capped, allowing the state to work towards its budget goals.
Note that the cap was raised from $22,083 for FY 2005/2006 to $22,525 for FY
2006/2007.
- In 2006 the statewide mental retardation waiting list reached 24,927
people. People observe that use of a cap within the PFDS Waiver has helped the
state to serve more people than could have been served with only the
Consolidated Waiver.
- State officials would like to accommodate all emergency
cases identified within the wait-list but realize that such action will
require additional funds. There is widespread agreement that the waiting list
remains a major concern.
- State officials are striving to promote
consumer-direction through both waivers. The intent is to work out
various operational issues pertaining to self-direction involving how to set
individual budgets, service planning, budget authority, and quality assurance.
- Rebalancing the long-term care system and refinancing community
services are not primary policy goals. Overall 80 percent of services are
financed through the waiver with the remainder paid for by county or state
dollars.
- The state has two other goals which are both aimed at the use of more
integrated settings. For example, state officials want to increase community
employment, moving from sheltered work experiences to supported employment
opportunities.
Wait-lists
Question: How many people are on the consolidated (i.e., all
wait-lists for developmental disabilities services) wait-list?
- OMR uses the Prioritization of Urgency of Need for Services (PUNS)
system to track wait-lists. In 2003, OMR began to collect PUNS information
electronically; therefore the 2003 data may not accurately depict a full year
of waiting list information. In addition, the PUNS form was revised in early
2006, which may have also affected the data. For these reasons, it is difficult
to compare waiting list data across years. These limitations aside, this
information tracking system allows the state to detect increased demand for its
community waiver services over time.
Year |
Emergency |
Critical |
Planning |
Total |
2006 |
3,274 |
9,999 |
11,654 |
24,927 |
2005 |
2,231 |
8,365 |
10,626 |
21,222 |
2004 |
1,920 |
7,463 |
10,181 |
19,564 |
2003 |
1,537 |
5,826 |
5,240 |
12,603 |
Question: How are wait-lists maintained?
- Local supports coordinators complete the PUNS with the individual and
family and counties use the PUNS data for budgeting and planning. The state
uses the PUNS system to maintain a comprehensive waiting list using its three
categories of need.
- The emergency category indicates a need within the next six
months.
- The critical category indicates a need in more than six months,
but less than two years.
- The planning category indicates a need in more than two but less
than five years.
Question: How long generally is the wait?
- The average length of time for those in the emergency category
alone is a year (369 days).
- The average time on the planning list before an individual is
enrolled is 643 days. This includes people who seeking services at a future
date, such as upon transition out of the special education system.
- People are selected for enrollment based on the categories of need,
generally with emergency cases being chosen first.
Basic Operations
Note that OMR expects to apply to CMS to alter certain features of the
PFDS Waiver within the next 12 months during the waiver renewal process.
Currently Pennsylvania is moving away from program funding to fee-for-service
payments. OMR is establishing new requirements on county administrative
entities to increase waiver recipient control, choice, and to create more
consistent waiver experiences for recipients across the state.
Question: Is there descriptive information available on the
people served in the supports waiver (e.g., age, primary disability, living
arrangement, functional status, caregivers)? Is systematic information
available regarding waiver impacts?
- Individuals are generally described as younger and living on their
own or at home with their families.
- More descriptive information is available in the states Home
and Community Services Information System to describe individual
characteristics such as age, primary and secondary disability and living
arrangement, though state officials plan to improve the available information.
- Systematic information about the impact of the supports waiver on
participant costs is available with some limitations. Additionally,
Pennsylvania conducts consumer satisfaction Interviews through an independent
monitoring process. The process involves interviews with a sample of individual
receiving services and their family and friends.
- The CMS reviews, quality assurance surveys, and the evaluation and
monitoring of counties by the OMR provide formal evaluations of the PFDS
Waiver.
Question: How are individual service plans developed?
- Local supports coordinators meet with the person and their family or
representative/legal guardian to complete a needs assessment. Subsequently, an
ISP is developed to address the identified needs.
Question: How are individual allocations set?
- Needs assessment is conducted every year as part of the planning
process. Currently, there is not a consistent statewide needs assessment;
however, OMR will begin implementing the Supports Intensity Scale as the
standardized needs assessment tool starting in September 2007. The needs
assessment results in the identification of support needs that are used by the
planning team to develop an ISP. The ISP includes services and supports
(including service units) to address the assessed needs. The individual budget
is established after the planning process, based on the needed waiver services
included in the plan.
Question: What decision-making authority do
individuals/families have over the budget?
- OMR has instructed County Programs to provide participants with their
individual budget upon request. Yet, informants note that some counties do not
consistently follow this policy. State officials plan to develop and implement
a more systematic protocol for setting individual budgets.
Question: Who has primary responsibility for developing
the service plan?
- Local supports coordinators develop ISPs through a person-centered
planning process.
- Among the supports coordinators, the average caseload is 50
individuals.
- The support coordinator caseloads presently range from 14 to 55
individuals.
- Participants may access personal support services to assist in
developing the service plan.
Question: Does the service planning include a distinct risk
assessment process to identify and address identified risk?
- ISPs are developed using a standardized format, which includes
components related to risk, which are discussed during the planning process.
However, the planning process does not include a distinct risk assessment
protocol. Negotiated risk agreements are not used. OMR is in the early stages
of developing a distinct risk assessment tool for use in planning.
- OMR utilizes additional mechanisms to identify and remediate risk.
First, the statewide incident reporting system and policies generate
standardized incident reports, which are reviewed by counties and OMR Regional
Offices. The individual and systemic review of incident reports can result in
the identification of risk issues, as well as opportunities for improvement. In
addition, OMR relies on inspections of licensed providers to reveal potential
risk issues. Any identified issues are relayed to the provider, and are
addressed through provider plans of correction. OMR reviews incident, licensing
and other information as part of its Regional Risk Management teams, and
reports findings to the appropriate provider and county.
- OMR expects providers and counties to conduct analysis of their risk
management and review procedures. Generally, OMR believes that risk management
is working well.
Question: Is the process the same or different from that used
in the comprehensive waiver?
- The process is the same as that used in the Consolidated Waiver.
Question: What happens to individuals when they need more
support than the waiver can offer, either by way of particular services and/or
overall cost?
- Supports coordinators review other options that can be used, such as
the communitys natural supports or additional assistance using state
dollars. State officials incorporate the potential for such cases within its
budgeting process and transfer individuals into the Consolidated Waiver as
necessary.
Question: How might a person be disenrolled from the supports
waiver?
- An individual may be disenrolled from the PFDS Waiver when the
individual: (a) requests such action; (b) is incarcerated; (c) no longer has a
disability; (d) is no longer financial eligible; (e) moves out of state; (f) no
longer meets level of care; (g) is admitted to nursing facility or ICF/MR; (h)
is no longer eligible for Medicaid; (i) refuses services; or (j) fails to
cooperate with waiver requirements.
Question: What if the individual wants to change their service
plan, or wants to change providers?
- The individual notifies his or her supports coordinator when they
need to change their plan or wish to change providers. The individual then
selects a new provider and a date is established for the new provider to begin
providing services. The supports coordinator works through the required
notifications and new authorizations.
Question: How is quality assurance and quality management
managed?
- The system used is the same as the Consolidated Waiver.
- Principle features include standardized monitoring forms used by
support coordinators, independent monitoring teams, and on-going evaluation by
OMR of local administrative entities that, with one exception, are counties.
- A strong feature of both waivers is the use of health care quality
units and the use of certified investigators to investigate certain types of
incidents at the state, county, and provider levels.
- The state participates in the National Core Indicators project that
tracks approximately 100 consumer, family, systemic, cost, and health and
safety outcomes -- outcomes that are important to understanding the overall
health of public mental retardation agencies.
- The state will be stepping up oversight of ISPs and its oversight of
administrative entities.
- One challenge for the implementation of standardized supports
coordination monitoring is increasingly large caseloads that sometimes make the
monitoring role difficult for the supports coordinators to fulfill.
Question: How are complaints resolved?
- Informal complaints can be made to OMR at its toll-free customer
service number, or to the OMR Regional Offices. Informal complaints are also
made directly to supports coordinators, supports coordination entities,
counties, and providers.
- Many complaints come from people on the wait-list who want to acquire
waiver services sooner.
- The formal complaint process (fair hearing and appeal) takes time and
the state asks people to submit their request within ten days. Participants,
however, have 30 days to appeal a decision. There are specified time lines and
checks in the process that begin at the county level and move to the state
level. It is felt by some that complaint handling has improved.
- OMR conducts a Service Review of certain waiver appeals for the
purpose of evaluating county compliance with applicable policies and
requirements. The Service Review results in state findings, which are
distributed to the individual/family, the county, and the Department of Public
Welfares (DPWs) Bureau of Hearing and Appeals. Upon receipt of the
Service Review findings, the individual/family can choose to continue on to
fair hearing or withdraw their appeal.
- Some feel that the Fair Hearing process option is not always
accessible for individuals and tends to be highly technical with hearing
officers who are not versed in the rights and protections intended in the
waivers. OMR is planning training for hearing officers in an effort to
alleviate some of these issues.
Question: What is the process that is used to monitor the
health and well-being of individuals participating in the supports waiver?
- The process includes mix of preventative activities (i.e., provider
training, provider background and abuse registry checks, pre-employment
screenings), on-going monitoring (i.e., supports coordination, local provider
monitoring, and consumer satisfaction interviews).
- A key difference between the PFDS and Consolidated waivers is that
the Consolidated Waiver requires more frequent face-to-face visiting.
- The Consolidated Waiver requires three face-to-face visits each
quarter with one at the waiver participants residence, one at the waiver
participants day service, and one at any place agreeable to the waiver
participant.
- The PFDS Waiver requires face-to-face monitoring at least every
six months with contact every three months for people living with a family
member. The minimum frequency is increased for people living in their own
homes, Personal Care Homes, or Domiciliary Care Homes to face-to-face
monitoring at least every three months and contact at least once a month.
- Supports coordinators, and their supervisors, follow-up on issues to
resolve them when monitoring reveals problems.
Opinions on Waiver Operations and Effects
Access to the Waiver
Explanation: Access refers to how easily people can apply for
and gain admission to the supports waiver.
- Potential enrollees can learn about the PFDS Waiver in a wide variety
of ways including: searching the blue pages in the phone book, local county
assistance offices, informational fliers, and extensive statewide family
training. Information is also presented by way of a 24 page guide to waiver
services and through the DPW website. Local intake staff members also describe
the services available and other sources, including educators in the school
system, often make referrals.
- Informants note that the PFDS Waiver is Somewhat
publicized and is well known within the system. Individuals apply for the
program through contacting the local county assistance office, using the
telephone, using the mail, or through the Internet.
- Informants note that it is Somewhat Easy to apply and
that demand for this waiver among people is increasing Somewhat.
Service Planning
Explanation: Service planning refers to the process to develop
individual support plans for waiver recipients.
- Overall, respondents indicated that recipients Very Much
lead the planning process, but Somewhat define their own service
needs. OMR is firmly committed to the person-centered approach and uses a
standardized format to develop the plan, which is entered into the state
information system.
- Overall, respondents indicated that recipients Somewhat
choose agencies or support givers to offer the needed support.
- Overall, respondents indicated that individuals exercise
Some choice and control over support plans, but it depends a lot on
the people involved. People can hire their own staff and act as employer
of record (through Vendor Fiscal Intermediary Service Organizations
(ISOs)) or hire an agency to manage this function (through Agency with Choice
ISOs).
- Overall, respondents indicated that supports coordinators
Somewhat know the individuals they are planning for because of high
turnover and high caseloads. The state is increasingly professionalizing the
role of supports coordinators and is in the process of developing a supports
coordinator curriculum and increased credentialing.
- Individuals may access personal support services to assist them in
putting together their plan and/or negotiating services.
- Informants indicate that the services available through these waivers
are generally broad enough to meet participant needs.
- Overall, respondents indicated that it is neither Easy
nor Hard for recipients to change their support plans because they
can begin the process to change with a simple telephone call to their supports
coordinator. However, the approval process can be cumbersome and it can take
30-60 days to make changes. There is currently an OMR-led work group that is
currently working on improving this process.
- Statewide consistency regarding application of the PFDS Waiver has
been an issue. Protocols pertaining to wait-list management, training, and plan
formation have been or are being, standardized. Efforts are being made to
increase the expectations of county performance and measure quality around the
state in systematic ways.
Service Delivery and Safeguards
Explanation: Service delivery and safeguards refers to the
services that individuals received and their operations, and the safeguards in
place to assure health and well-being.
- Informants indicate that once services are authorized, it is
Very Easy for individuals to receive services with only a few
exceptions. Once the approval process has been completed the only problem that
emerges are the few times that agencies have been unable to hire or maintain
staff.
- Informants indicate that services to promote community integration
are emphasized over services that are more traditional (e.g., sheltered work,
enclaves, segregated activities).
- Informants indicate that it is Somewhat Easy for
individuals to change service providers and this generally takes weeks to
months.
- Waiver recipients can hire and manage their own qualified support
workers through vendor fiscal ISOs or with an agency with choice ISO serving as
the the employer of record. Sometimes recipients choose an agency
to hire and manage support workers. These options are being utilized a small
percentage of the time but OMR expects the use of this option to grow.
- In-home supports utilized by adults living at home with
family are most often family directed but sometimes are person-directed or
both.
- Workforce issues related to liability have not been a concern to
date.
- Informants generally indicate that the safeguards in place are
working well. The active participation of families in the PFDS Waiver is
helpful.
Satisfaction with Outcomes
- Generally, informants indicate that the PFDS Waiver encourages people
to seek, acquire and hold integrated employment. There are two relevant
services, job support and job finding, and OMR encourages people to utilize
these services more. Across all of its mental retardation county services in
January 2006 there were 2,366 people competitively employed, 2,768 employed
through supported employment, and 7,565 in vocational programs. Others feel,
however, that there is little opportunity for employment.
- OMR indicates that generally people live on their own or with
friends. Some feel, however, that people do not live on their own or with
friends often enough. There is shared agreement that people in the PFDS Waiver
participate in community events.
Key Issues in Play
Question: What are the waivers greatest strengths?
- A major strength of the PFDS Waiver is its demonstrated ability to
serve a large number of services recipients at a lower-cost.
- There is widespread agreement that the PFDS Waiver has been effective
at addressing the wait-list.
- There is common agreement that the statewide training efforts are
first rate with support from the highest levels. There are at least three
highlights to this statewide training.
- The Partnership is a coalition of five self-advocacy
and family groups and Temple Universitys Institute on Disabilities that
has provided 250 training sessions in the last three years to over 5,000 people
in each of the 67 counties throughout the state. This million dollar effort has
led to a survey of topics that people have felt were needed and the formation
of a series of two hour power points that are used by a train the trainer model
to share with families and individuals across Pennsylvania. The curriculum
currently includes eight topics for self advocates and seven topics for
families and is also available to professionals.
- The College of Direct Support, available by Internet has
attracted over 17,000 learners in the past four years. One new learning group
that has appeared recently is comprised of direct support workers who provide
PFDS Waiver services.
- The OMR Academy for Administrative Entities is
managed by OMR and reaches County Programs/administrative entities to share
information and standardize processes.
- There is agreement that the PFDS Waiver should increasingly emphasize
integrated employment.
- The incident reporting system and self-advocacy efforts are commonly
viewed by many as strong and a positive parts of the service system.
- The increasing emphasis of the PFDS Waiver on individuals directing
their own services is considered by many as a strength.
Question: What are the barriers to achieving the waivers
goals?
- The absence of sufficient funding inhibits efforts to increase access
to the PFDS Waiver.
- There is a lack of consistency with PFDS Waiver policy and its
application across the state that needs to be overcome.
- Some note that there are some unreported cases of abuse of waiver
recipients who are minors. The reliance within the PFDS Waiver on families may
leave individuals vulnerable to such abuse.
Question: Are there topics where there is disagreement or
concern?
- One issue is how much control families and individuals have and how
much is retained by counties and providers.
- There is no adult protective service system currently in the
Commonwealth of Pennsylvania for people age 18-59. There is proposed
legislation to add this protection and all agree that is creates undesirable
risks for many individuals in the state as well as, unfortunately, some PFDS
Waiver participants.
- One challenge that is frequently mentioned is keeping the PFDS Waiver
theory real in practice across the state.
- Some feel that, to this day, the counties control the supports
coordinators who in turn control the support planning and this leaves the
waiver recipient faced with a county that essentially needs to balance its
budget.
Question: What are the TOP THREE things that could be done to
improve the waiver?
- OMR should move decisively to assure consistency in the application
of waiver policies throughout the state.
- Pennsylvania is also eager to clarify policies and its expectations
pertaining to self-direction, including issues associated with setting
individual budgets and potential tensions over whether services are actually
individual or family directed.
- There is a statewide push to standardize quality management across
the state. In revamping quality management, OMR is stressing communicating
better with stakeholders while it designs the final structure and identifies
priorities.
Question: What other points should be raised?
- In Pennsylvania there is a constant tension between the need to
address a large standing waiting list and improving service delivery.
- There is a need to improve information management systems to keep
pace with changes in service design and delivery.
Overall Impressions
All informants agreed that the PFDS Waiver has helped people gain access
to supports and move off the waiting list. There is also widespread agreement
that the statewide training efforts that support individuals and families
involved in the supports waiver are top notch. Meanwhile, OMR is working to
achieve more consistency in the application of its waiver policies across the
state. Overall, the PFDS Waiver is one of the tools that Pennsylvania uses to
address its waiting list and contain costs. Added to that it seeks to explore
and establish consistent practices that, from the onset of enrollment on,
promote self-direction and community integration.
Introduction
The Tennessee Self-Determination Waiver Program (SDWP) is designed for
children and adults with I&DD and was launched in 2005. Its major aim is to
address the wait-list, but gives priority according to urgency of need. First
priority for enrollment is afforded persons in the crisis, then
with an urgent need, and finally to those categorized as
active. Potential enrollees must have a non-institutional place of
residence where they live with their families, non-related caregiver or in
their own home, and have needs that can be met effectively by the combination
of waiver services and other available supports. Presently, the SDWP waiver
serves 800 participants, while the states comprehensive waiver serves
6,000 individuals.
Method
In August and September 2006, HSRI talked with key informants in
Tennessee to obtain more in-depth information concerning the SDWP. Informants
included: (a) state staff with the Division of Mental Retardation Services
(DMRS), including the state director, manager, and others; and (b)
representatives from interests outside the state agency, including
representatives of the state Protection and Advocacy Agency and families.
Results
The results of the key informant consultations follow. First,
information is presented to describe the policy goals of the waiver,
information on service wait-lists, and the fundamental waiver operations.
Second, the views expressed by the informants are summarized with respect to:
(a) access to the waiver; (b) waiver operations, service planning, service
delivery and safeguards; (c) outcomes; and (d) key issues in play.
Tennessee Policy Goals
Question: What are the major policy goals of the supports
waivers and how successful have the waivers been in meeting them?
- There is strong agreement that cost containment was a major policy
goal in launching SDWP. CMS had identified several major shortcomings with the
states comprehensive waiver (i.e., Statewide Mental Retardation Waiver
Program). CMS limited new waiver enrollment to individuals in crisis until
those problems were resolved. In January 2005, CMS approved a replacement
comprehensive waiver and the SDWP and subsequently approved the resumption of
waiver enrollments in March 2005. Since then, the SDWP has offered means for
children and adults to receive waiver services in a more cost efficient way
than through use of the comprehensive waiver alone.
- The SDWP waiver is viewed by all as cost effective and people
generally report being satisfied with their waiver services.
- Tennessee also views the SDWP as a useful means for addressing its
waiting list. Presently, 4,761 people are waiting services and state officials
expect the demand for services to continue to scale up.
- While the SDWP waiver provides for consumer-direction, there has been
limited implementation thus far.
- Rebalancing the long-term care system and refinancing community
services were not major policy goals in launching SDWP.
- The SDWP was a direct outgrowth of the 2004 Brown vs. Tennessee
Department of Finance and Administration waiting list lawsuit settlement
agreement. The settlement provided for Tennessee to create a new waiver that
specifically targeted children and adults with I&DD who were wait-listed
for services and could be supported in the family home or other non-licensed
living arrangements. SDWP waiver enrollment is expected to reach 1,500 persons
in its third year.
Wait-lists
Question: How many people are on the consolidated (i.e., all
wait-lists for developmental disabilities services) wait-list?
- The accompanying table shows the number of children and adults on the
consolidated wait-list. Overall, about 1,000 individuals on the waiting list
are inactive. The remainder includes 818 applicants in the crisis
category and 422 who have urgent needs.
2006 |
4,761 |
2005 |
4,046 |
2004 |
3,660 |
2003 |
3,663 |
- The waiting list has grown by 1,300 people since the settlement but
1,900 people have been enrolled in the state waiver programs. People First of
Tennessee has made the waiting list reduction its primary goal.
- Many, 43 percent now and 46 percent six years ago, of new waiver
recipients come from school referrals. However, there are potentially 2,000 new
children each year that are possible support waiver referrals and their
presence is understated on the current waiting list.
Question: How are wait-lists maintained?
- State case managers maintain waiting lists and track the status of
people who are seeking enrollment but for whom slots are not available by using
a priority system that accommodates emergency cases first. There is a process
enrollment committee that selects the absolutely most critical cases from the
states regions.
Question: How long generally is the wait?
- People in the crisis category can wait over one year and
the wait for some can last up to 13 years.
- In the last several months there have been 10-15 people enrolled into
the waiver a month, but given the resources available and the expected demand,
the waiting list may reach 12,000-15,000.
Basic Operations
Question: How are people selected for enrollment?
- Applicants are selected by the eight person process enrollment
committee.
Question: Is there descriptive information available on the
people served in the supports waiver (e.g., age, primary disability, living
arrangement, functional status, caregivers)? Is systematic information
available regarding waiver impacts?
- The state does not have a systemized electronic data retrieval system
for this purpose. The annual report and brochures broadly defines profiles of
those served in the supports waiver. Some descriptive information to profile
SDWP participants is available, however, resulting from various quality
management activities. Such information is compiled on spread sheets, but is
not easily available.
- Some information on the impact of the supports waiver on participant
costs is available with limitations. The state has the capability to sort
information by waiver, but these processes are new. The state is making needed
changes to build better databases but there is still more work to be done.
Informally, there are growing numbers of success stories from support waiver
recipients.
- The CMS reviews and state administered quality assurance surveys are
the current formal evaluations of the supports waiver.
Question: How are individual service plans developed?
- State case managers meet with individual recipients and their family
or representative/legal guardian to complete individual service plans.
Question: How are individual allocations set?
- The full cap of $30,000 for service components is available to the
recipient as long as they stay at or under the cap. Increases in the cap are
possible if circumstances warrant and justification is provided and accepted.
The total budget for all waiver services, including emergency assistance
services, may not exceed $36,000 per year per participant.
- Individuals have knowledge of the allocation before planning.
Question: What decision-making authority do
individuals/families have over the budget?
- They can plan within the funding limit and determine services and
supports needed. The general allocation process has category limits but these
can be worked around when necessary.
- There is a fiscal intermediary or payroll service available to help
the individual control or manage the amount allocated for his or her services.
Question: Who has primary responsibility for developing
the service plan?
- State case managers have primary responsibility for developing the
service plan.
- Among service planners the average annual caseload is 50 individuals
per planner.
- The case load range for service planners is from 35 to 50 individuals
per planner.
- In Tennessee people usually do not have paid outside assistance
available to them during the service planning process. Support brokers are
available later to help recipients with the waiver processes and managing
direct support staff.
Question: Does the service planning include a distinct risk
assessment process to identify and address identified risk?
- The service planning includes a distinct risk assessment process to
identify and address identified risks. Negotiated risk agreements are not used.
Question: Is the process the same or different from that used
in the comprehensive waiver?
- The planning process parallels the process used in the comprehensive
waiver.
Question: What happens to individuals when they need more
support than the waiver can offer, either by way of particular services and/or
overall cost?
- Other alternatives are identified by the case manager when available
to meet their needs. If none are available or identified, exceptions to
increasing the cap can be approved up to a point. Transfer to the comprehensive
waiver is possible when slots are available. If slots were not available, the
individuals would be placed on the waiting list.
Question: What parameters govern transition from the supports
waiver to the comprehensive waiver?
- Only in the most extreme cases of need are individuals able to move
from the supports waiver to the comprehensive waiver. So far, all such
individuals have been accommodated.
- An individual may be dis-enrolled from the supports waiver if the
health and safety of the individual or others cannot be assured or if the
individual: (a) no longer manages his or her own service (support waiver); (b)
is incarcerated; (c) no longer has a disability; (d) is no longer financial
eligible; (e) moves out of state; (f) no longer meets level of care; (g) is
admitted to nursing facility or ICF/MR; (h) is no longer eligible for Medicaid;
(i) refuses services; or (j) fails to cooperate. Two individuals have been
disenrolled in the past two years.
Question: What if the individual wants to change their service
plan, or wants to change providers?
- The individual must contact his or her case manager and declare their
want to change providers.
Question: How is quality assurance and quality management
managed?
- The principle features of the waivers Quality Assurance and
Quality Management System includes: (a) use of a dedicated Quality Management
Committee; (b) oversight by case manages; (c) consumer satisfaction surveys;
and (d) use annually, and even monthly, of an extensive, standardized quality
assurance tool.
- This system is the same as is used for the comprehensive waiver.
- Where problems are discovered, the state may fine providers or apply
other sanctions, provide technical assistance or training.
Question: How are complaints resolved?
- There are units within the regional or central offices to manage
complaints. To file a complaint, individuals make a formal complain through one
of these offices. Staff pursue investigations, act to reach resolution and
offer mediation though there have been very few mediations over time. Last year
there were 52 complaints statewide.
- Individuals may seek a fair hearing through this complaint procedure
or they may file a local grievance.
- In Fair Hearings, a hearing is held before a Hearing Officer
where the complainant requesting the appeal (and/or their representatives and
witnesses) presents their case with the state presenting theirs as well. The
Hearing Officer issues a written decision that can be appealed to the Director.
The Directors written decision can be appealed in District Court.
- In the grievance procedure, the grievant identifies their
grievance and a proposed resolution. A local official responds to the
grievance. This response can be appealed to a local governing body. If not
resolved there, the grievance moves to an independent administrative committee.
If not resolved at this level, the grievance may remain unresolved. In
administrative inquiries, quality assurance completes an investigation and
issues findings which may include provider citations.
Question: What is the process that is used to monitor the
health and well-being of individuals participating in the supports waiver?
- The process includes case management, provider training, consumer
satisfaction surveys, provider monitoring, provider background and abuse
registry checks, pre-employment screenings, and critical incident reporting.
The standardized monitoring tool that Tennessee uses to sort categories of need
for the waiting list also has a subset for monitoring health and well-being.
- In-person monitoring is performed a minimum of every six months.
- The differences between the approach to SDWP monitoring and
comprehensive waiver monitoring is that the comprehensive waiver requires more
frequent face to face visits by case managers. Quality management personnel
accumulate individual studies for future action and looks over time for problem
people and patterns.
- Case management is responsible for resolving problems identified
through monitoring.
- The state expects to change the supports waiver within the next 12
month by increasing internal monitoring of state case management and increased
technical assistance to support brokers. There is a request for proposal to
establish a permanent fiscal intermediary combined with support brokerage.
Opinions on Waiver Operations and Effects
Access to the Waiver
Explanation: Access refers to how easily people can apply for
and gain admission to the supports waiver.
- The potential enrollees and their families learn about this waiver
through generally through contact with printed matter such as a family
handbook or brochures, and through the website. Special educators also
frequently make referrals.
- Informants indicate that the supports waiver is somewhat
publicized and individuals apply for the program through regional state case
managers.
- It is very easy to apply and the demand for this waiver among people
is growing.
Service Planning
Explanation: Service planning refers to the process to develop
individual support plans for waiver recipients.
- Overall, state staff indicate that individuals Very Much
lead the planning process, define their own service needs, and choose the
agencies or support givers to offer the needed support.
- In contrast, advocates believe that individuals are not in the
drivers seat during the service plan development process.
- Overall, respondents indicate that recipients can exercise choice and
control over service plans and make decisions about trade offs. Financial
administration has been good.
- Overall, respondents indicate that service planners know the person
they are planning for Well or Somewhat. However, there
is turnover in staff and case load variations. It is a mixed bag. After the
lawsuit, the state progressed rapidly to institute the SDWP and case managers
were put into place and trained on-the-job. This led to quality problems
related to case management
- The services available through this waiver are generally broad enough
to meet participant needs. There are few requests for upward migration to the
comprehensive waiver.
- It is Very Easy for individuals to change their service
plans.
- The strengths of the individual planning approach are its ability to
allow people to choose services, hire staff, and decide on trade offs.
- Some see shortcomings as a lack of training and preparation for the
support waiver case managers.
Service Delivery and Safeguards
Explanation: Service delivery and safeguards refers to the
services that individuals received and their operations, and the safeguards in
place to assure health and well-being.
- Once services are authorized, it is very easy for individuals to get
the supports they need.
Satisfaction with Outcomes
Employment outcomes:
- Generally people do not seek/acquire/hold integrated employment
though it is a support waiver option that is being encouraged. A broad
coalition of support for Employment First! has led to an on-going
commitment across the state to expand integrated employment. As a component of
the Employment First! initiative, benchmark goals were developed to
track state progress in increasing integrated employment placements. Providers
are asked to report specific data on the number of people in integrated
employment, number of hours worked, wages earned per hour, and job title.
- The Employment First! Initiative boosted the number of
individuals with I&DD employed in competitive jobs by nearly 40 percent in
its three years of implementation. In 2002, when the Tennessee DMRS first
launched the Employment First! Initiative, there were about 1,100
individuals employed in competitive jobs. That number grew to 1,542 by the end
of December 2005.
Other outcomes:
- Generally, informants indicate that people can live on their own or
with friends. However, families are very protective.
- Generally, informants indicate that people in the supports waiver
participate in community events.
- There is some promotion in the waiver to promote community
integration versus services that are more traditional (e.g., sheltered work,
enclaves, and other segregated activities). However, many recipients continue
to use the segregated services. Overall integration happens the most often with
the family in regular community activities.
- There are currently 120 waiver recipients who hire and manage their
own support workers. While the workers are employed by an agency, they often
identify and refer potential workers to the agency and manage them on a day to
day basis. Support brokers can help and assist them in evaluating workers and
in filing the necessary forms.
- Where in-home supports are offered to adults living home
with family, the services are seen by the state as most often family directed.
This is true in the comprehensive waiver as well.
- To date, there have been no participants who have experienced major
health, abuse, or neglect issues.
Key Issues in Play
Question: What are the waivers greatest strengths?
- Its ability to serve a large number of services recipients
in-home while being cost effective with rapid deployment of the
supports. Most people see the SDWP as early in its development with greater
potentials for expanding self-determination.
- Generally, most individuals and families report being satisfied and
very happy with services. There is flexibility of selection and potentially
creative plans with enough services and components. People can stay home and
the waiver reduces parental burnout.
- The state hosts eight town meetings each year and is working on
better connections with school districts to help transitioning students become
accomplished waiver recipients with more planning and fewer surprises for all
parties.
- People have hope of getting off the waiting list and receiving
services. The caps make people careful about what they select and careful what
they buy.
- It allows for more flexibility and control for people with
disabilities and family members in service delivery.
Question: What are the barriers to achieving the waivers
goals?
- Tennessee has a large waiting list.
- Self-determination is often seen by many as an all or nothing
proposition. This can cause people not to want to pursue it.
- Improvements are needed in case management and support brokering. The
support waiver needed to begin quickly which meant the case managers did not
have as much time to be trained and oriented to the new waiver. Case management
case loads have grown too large. Their comprehensive waiver counterparts have
been organized and operating for some time. More training, mentoring, and
monitoring is needed by the support waiver case managers and support brokers.
They need more information about the possibilities the supports waivers offer
and what people can do. The support broker role is new and offers an
opportunity for recipients and their families to have much more help in
individualizing and customizing their own supports and plan.
- Services offered by licensed clinicians and therapists might be
delivered more cost effectively by professionally guided direct service
workers.
- People need more information about how to utilize other sources of
supports. The series of lawsuits and newness of the support waiver have left
many stakeholders afraid, uncertain and not trusting communications and regular
state information.
Question: Are there topics where there is disagreement or
concern?
- People on the waiting list remain unserved and so are accorded no
safeguards or support.
- Tennessee direct support professionals and Tennesseans with
disabilities earn low wages, often have limited career paths, and have trouble
finding affordable (accessible, and safe) homes to buy.
- Community providers have difficulty maintaining a stable workforce.
Low ages in the community are a problem.
- There are difficulties concerning differences in service provision
requirements for various therapies provided under the waiver as opposed to the
state Medicaid plan. State officials are working to make these differences more
apparent to reduce unintended errors.
- There is a need to continue to train and monitor state case managers.
- It is presently very difficult to monitor costs; millions of dollars
can be spent before it is realized. Better information management systems are
needed.
- More should be done to increase information sharing about the
supports waiver, the opportunities it brings for self-direction and emerging
best practices.
Question: What are the TOP THREE things that could be done to
improve the waiver?
- Add funds to eliminate the waiting list or increase the existing cap
on the support waiver, for example to $50,000, to enroll people that would
otherwise be in the more expensive and uncapped comprehensive waiver.
- More should be done to promote additional legislative and political
support for the SDWP.
- Overall, there is a crying need for sharing information to help
people obtain the supports they need.
Question: What other points should be raised?
- The SDWP is relatively new, and innovation should be encouraged.
- About five million new dollars is needed to bolster the existing
comprehensive waiver. This is difficult choice because of the waiting list but
is probably unavoidable.
Overall Impressions
All informants agree that the SDWP is making important contributions to
supporting people with I&DD in the community, although it is still early in
its development. CMS has influenced much of the decision-making to this point
because of the shortcomings that it found in the operation of the comprehensive
waiver. Now, however, it is time for state officials to step back and determine
how the supports waiver can be best applied and shaped to improve the overall
system of services. Clearly, the SDWP is a strong tool for containing costs and
addressing the wait-list. Yet, much underlying infrastructure must still be
developed, such as developing improved information management systems, assuring
the presence of well-trained case managers and an agile provider community, and
working out operational procedures to promote self-direction. Still, most agree
that the SDWP has had a good start.