HHS System Strategic Plan for FY
2005-2009
Chapter VI:
Department of Aging and Disability Services
External/Internal Assessment
Contents:
<<back to top>>
The Department of Aging and Disability Services (DADS) was created by
House Bill 2292, 78th Legislature, Regular Session, 2003, to administer
human services programs for the aging, for persons with disabilities, and
for persons with mental retardation. The Department is scheduled to begin
formal operations on September 1, 2004.
The material in this chapter is arranged as follows:
- Challenges and Opportunities;
- Current Activities by Goal:
- Service Descriptions;
- Target Populations; and
- Other Trends and Initiatives;
- Internal Assessment; and
- Strategic Priorities.
For consistency, the same outline is used in each of the agency
chapters.
<<back to top>>
Maintain the Continuum of Services for Older Texans
The aging of the population is an HHS system challenge as discussed in
Chapter III, and it has important implications for DADS service delivery
to older Texans. House Bill 2292 requires DADS to serve as the Texas State
Unit on Aging (SUA) under the Older Americans Act (OAA) of 1965 and to
implement the requirements of Texas Human Resource Code Section 101.022.
Older Americans Act programs are designed to help people 60 ages and over
maintain their health, personal independence, dignity, and ability to
contribute to society. The major functions of the State Unit on Aging are:
- Administering and ensuring accountability for funding of services
and opportunities through a network of 28 area agencies on aging;
- Improving state and local capacity for "Aging Texas Well"
by serving as a comprehensive resource, developing tools and
resources, establishing public-private partnerships, and conducting
policy research; and
- Advocating for residents of long-term care facilities and older
Texans in general.
To meet the challenges presented by the OAA, the Department has placed
the State Unit on Aging Oversight function under the direction of the
Center for Program Coordination. This will serve as the visible focal
point required by the OAA and will ensure compliance with its other
provisions.
The Department must comply with requirements in the OAA to ensure that
federal funds under the OAA are not jeopardized. Within the context of a
new, large agency, DADS will establish appropriate management processes to
continue the holistic approach by the legacy agency to aging issues and
provision of a full-continuum of services authorized by the Act.
Contracting and Oversight of Local MR System
Several changes occurring simultaneously pose challenges to the
contracting and oversight of local community centers' service delivery.
Currently operating with a unified contract and multidisciplinary team
oversight, community mental health (MH) and mental retardation (MR) or (MH/MR)
centers and the services they offer will be challenged by the split of
mental health and mental retardation programs into two separate
departments. For fiscal year (FY) 2005, performance contracts with local
authorities will be developed jointly by DSHS, DADS, and the local MHMR
authority. Additionally, as a result of S.B. 1182, 78th Legislature,
Regular Session, 2003, the performance contract between local authorities
and the respective department is being piloted in two local authorities in
FY 2005. In the pilots, performance contracts will be individually
negotiated, based on the needs and priorities identified in the local
service area plan developed by each of the local authorities. The two
departments will need to work closely together to ensure a holistic
approach in oversight of the community MHMR centers. Pilot results may
determine an approach to facilitate oversight functions.
A complicating factor is the shift in funding methodology for general
revenue (GR) funded services, from a quarterly allocation of funds
(grant-in-aid) to a reimbursement methodology (fee-for-service) and the
establishment of the necessary infrastructure to support the new system.
Disruptions in provider cash flow must be avoided, as they could impact
consumer services and overall financial viability.
Continued development of the cost accounting methodology and the
encounter-based reporting of service delivery will allow the Department to
assess the amount, scope, duration, and cost of GR-funded services. These
processes and the shift to fee-for-service reimbursement will help
maximize the use of state dollars by enabling the Department to identify
consumers who might be appropriate for refinancing to waiver services. The
fee-for-service model also allows DADS to align GR-funded services more
closely with waiver program services, leading to a unified
claims-processing system, a single set of utilization management
guidelines, and a quality management oversight system that crosses funding
streams.
Privatizing Community ICF/MR and Waiver Services
Among the provisions of H.B. 2292 is the requirement that the local MH
and MR authorities may provide services only as a provider of last resort.
Additionally, the bill requires privatization of all ICF/MR and waiver
services programs operated by a local authority. This transfer of services
to private providers may not occur before September 1, 2006. However, the
development of the plan to transition services to private providers and
the process of assembling a network of service providers to meet this
mandate will need to begin well in advance of that date to ensure minimal
disruption of services to the consumer.
The local service area plans, developed by the local MR authorities,
identify the service needs and gaps of their consumer population. As new
providers are identified to meet the privatization requirements of H.B.
2292, they will be required to demonstrate their ability to meet all the
needs of the consumer population. The option to use the local authority as
the provider of last resort is a mechanism to address gaps in services
during the transition.
Increased Demand for Community- and Home-Based Services
Over the past two decades, public policy has increasingly emphasized
long-term services in the community rather than institutional settings.
For the past five years, this trend has been accelerated by policy
direction established by the Olmstead decision.
As the Department reviews its services and funding mechanisms, there
may be opportunities to restructure community programs and develop
alternate methods to deliver services with greater efficiency. Efforts to
ensure that services make maximum use of Medicaid funding will continue,
with added efforts to ensure that services are tailored to specific
consumer needs and circumstances. As new tools for assessment and service
delivery are implemented, the Department will provide services more
effectively. The Department will use various funding resources, depending
on availability and individual circumstances. These efforts toward
effectiveness and efficiency will serve more people and serve them better,
but they may not keep pace with the demand in the coming years.
Integration of Quality Assurance and Improvement
The development of long-term care services and supports in the
community has evolved to meet the changing needs and preferences of
consumers. For example, the community ICF/MR programs, multiple Medicaid
waiver programs, and various state-funded programs each have their own
sets of oversight and monitoring requirements. Ensuring that standards of
care are met, conditions of participation are achieved, and program and
consumer outcomes occur as desired will present a major challenge to DADS.
Transferring the various Medicaid waiver programs operated by legacy
agencies to DADS will provide the opportunity to design a single quality
assurance/quality improvement system, incorporating person-directed
planning, consumer choice, and control where appropriate, and
outcome-based evaluation mechanisms across all program services. Alignment
of GR services with waiver services allows this quality initiative to be
expanded across funding streams as well. The receipt of federal quality
assurance/quality improvement grant monies will significantly aid this
quality system development.
Implementing the quality assurance/quality improvement grant for the
HCS waiver will provide valuable lessons on how DADS may enhance quality
assurance and quality improvement efforts in other programs.
<<back to top>>
DADS Goal 1: Long-Term Care
To enable older Texans to live dignified, independent, and
productive lives in a safe living environment through an accessible,
locally-based, comprehensive and coordinated continuum of services and
opportunities, to provide appropriate care based on individual needs
ranging from in-home and community-based services for elderly people and
people with disabilities who request assistance in maintaining their
independence and increasing their quality of life, to institutional care
for those who require that level of support, seeking to ensure health and
safety and to maintain maximum independence for the client while providing
the support required.
Qualifying older persons and people with disabilities throughout Texas
have access to long-term care services through a network of 41 local
community mental retardation authorities (MRAs), 28 Area Agencies on Aging
(AAAs), and 10 regional administrative divisions supporting local offices.
These entities provide a full continuum of services, to meet the diverse
needs of people with disabilities and people over age 60. The following is
a brief description of those services.
Aging Services
Service Description
The 28 AAAs provide three major types of services: access and assistance,
nutrition, and supportive services, including services for informal
caregivers. These services are generally short term, to meet immediate
needs until long-term services are available. The AAA services may also be
used to provide support while the client or family circumstances stabilize
and other resources are identified to meet the long-term client/caregiver
service needs.
- Access and Assistance Services-usually provided directly by
the AAA, include information, referral and assistance, care
coordination, legal assistance/benefits counseling, caregiver support
coordination, and long-term care ombudsman services. These services
identify appropriate client needs through an intake and assessment
process, and they assist the client in developing a plan of care and
arranging services, which may be paid for by the AAA, other service
entitlements, or private pay. Benefits counselors help consumers
understand and obtain benefit entitlements. Follow-up activities, an
integral part of this service, ensure the clients' needs are met in
the best way and with the highest quality possible. The long-term
ombudsman services use staff and more than 800 certified volunteers to
serve as advocates for residents of long-term care facilities-nursing
facilities and, increasingly, assisted living facilities.
- Nutrition Services-identified in the OAA as health promotion
services provided through congregate and home-delivered meals.
Congregate meals are provided in a congregate setting, which include
nutrition sites, multipurpose senior centers, adult day care
facilities, and multigenerational meal sites. Home-delivered meals are
provided to those seniors who are assessed as homebound, frail.
Nutrition services are provided through subcontractors or vendors, who
must comply with the one-third recommended daily allowance and with
the Dietary Guidelines for Americans, published by the Secretary of
Agriculture. The OAA requires nutrition education and other elder
nutrition services, such as follow-up for those clients identified as
having a high nutritional risk.
- Supportive Services-to help older people to lead independent,
meaningful, and dignified lives in their own homes and communities as
long as possible. Supportive services include services such as
transportation, health maintenance, health screening, income support,
and training. In-home support services include homemaker, personal
assistance, visiting, telephone reassurance, chore maintenance,
respite care, minor residential repair, and other services as may be
identified by the State Unit on Aging (SUA) in the State Plan required
by federal law. These services are provided through subcontractors, or
they may be authorized by the AAAs through coordination of care and/or
caregiver support.
The National Family Caregiver Support Program, authorized by the OAA
Amendments of 2000, provides critical support that families need in
maintaining their caregiver roles. Under this program, informal caregivers
are defined as either individuals caring for persons ages 60 and over, or
grandparents ages 60 and over caring for a grandchild younger than 18
years. The AAAs provide support in information, assistance, counseling,
and support groups, respite, and supplemental supportive services
described above. Supplemental services are provided on a limited basis, to
complement the care provided by caregivers. Services provided under this
category include fixed route transportation, demand/response
transportation, assisted transportation, emergency response, escort,
home-delivered meals, homemaker, personal assistance, shopping, telephone
reassurance, chore maintenance, health maintenance, income support, and
residential repair.
Target Population
The sole eligibility requirement for services under the OAA is to be 60
years of age or over, or be a family member or caregiver seeking support
on behalf of someone age 60 or over. However, OAA services target older
individuals with the greatest social and economic need. Targeting and
outreach activities include specific objectives for providing services to
low-income minority individuals and older individuals residing in rural
areas.
As shown in Table 6.1, Texas will experience an increase in each of
these target populations. The percentage of older individuals with low
incomes is expected to increase by nearly 38 percent between the years
2000 and 2010. The percent of older individuals living in rural areas
between 2000 and 2010 is expected to increase by 31 percent. The greatest
percentage increase is anticipated among the older minority population;
between 2000 and 2010, this portion of the aging population is expected to
grow by nearly 55 percent.
Table 6.1
Projected Growth in Target Populations for Aging Services
| Target Population |
2000 |
2010 |
% change |
| 60+ Low-Income1 |
334,622 |
460,267 |
+37.5% |
| 60+ Rural2 |
474,091 |
620,995 |
+31.0% |
| 60+ Minority |
782,836 |
1,210,411 |
+54.6% |
- Low-income is defined as 100% of the Federal Poverty Level.
Low-income projections assume the poverty rate remains constant.
- Rural projections assume the rate of seniors living in a rural area
remains constant. Counties identified as rural have 51 percent or more
of their population living in a rural area.
Table 6.1: U.S. Census Bureau, Census 2000, Public Use Microdata
Sample (PUMS), Texas State Data Center, Population Growth Scenario 0.5,
2004.
Long-Term Care Services
Service Description
Long-term care services for persons who are older or have a disability
include both community-based and institutional programs. Community-based
services may be provided with or without waivers and are available to
people with disabilities who meet functional, medical, and financial need
criteria.
These services may be provided through Medicaid funds, Social Services
Block Grant funds, or GR appropriations:
- Primary Home Care and Community Attendant Services-Non-technical
personal care services provided to persons of all ages who are
functionally limited in performing activities of daily living
(personal care, home management, escort), with medical need
established by a practitioner.
- Family Care-services provided to aged people and adults with
disabilities who are functionally limited in performing daily living
activities. Services include assistance with personal care activities,
housekeeping tasks, meal preparation, and escort services.
- Day Activity and Health Services-nursing, physical
rehabilitative, nutrition, and supportive services prescribed by a
physician and provided in adult day-care facilities that are state
licensed.
- Home Delivered Meals-hot, nutritious meals served in a
client's home by community-based provider agencies.
- Emergency Response-a 24-hour, electronic, medical emergency
call system for functionally impaired older people or adults with
disabilities who live alone or are physically isolated from the
community.
- Residential Care-services to adults who require access to
services on a 24-hour basis, but who do not need daily nursing
intervention. Care is provided in facilities licensed by DADS.
- Adult Foster Care-24-hour living arrangements, including meal
preparation, housekeeping, and help with personal care.
- Consumer Managed Personal Assistant Services-services
targeting adults with disabilities who are mentally and emotionally
capable of self-directing their attendant care. Clients interview,
hire, train, and supervise their own attendants.
- In-Home and Family Support Services-grant benefits to persons
who are older or have disabilities, to support their living
independently in the community and to prevent institutionalization.
The consumer may use the benefits to purchase special equipment,
medical supplies, and adaptive aids and also to modify the home and
automobile to make them accessible and usable.
- Hospice Program-medical, social, and support services to
terminally ill patients in the community or in an institution.
As an alternative to institutionalization, states may apply for waivers
to allow Medicaid consumers to receive services in a community or home
setting. The following are waiver services provided in the community:
- Community Based Alternatives (CBA)-home- and community-based
services to people who are older and to adults with disabilities, as a
cost-effective alternative to nursing facilities. Consumers must meet
medical necessity requirements for nursing facility services. As the
largest waiver program, CBA served about 30,300 Texans each month in
FY 2003.
- Community Living Assistance and Support Services (CLASS)-home-
and community-based services, as a cost-effective alternative to
placement in an ICF/MR. In FY 2003, this program provided services to
more than 1,860 consumers per month.
- Deaf-Blind with Multiple Disabilities (DBMD)-serving people
who are both deaf and blind and have at least one other disability, to
help them communicate and live as independently as possible. In FY
2003, this program served about 130 consumers per month.
- Medically Dependent Children Program (MDCP)-support services
to families with medically complex or fragile children to help the
children remain at home and out of long-term care facilities. The
program provides respite care, minor home modification, adaptive aids,
and adjunct services. In FY 2003, this program provided services to
about 985 consumers per month.
- Consolidated Waiver Program (CWP)-a program in Bexar County,
providing home- and community-based services to people eligible for
care in a nursing facility or ICF/MR. This cost-effective alternative
to institutional placement served approximately 200 clients in FY
2003.
In addition, the Program for All-Inclusive Care of the Elderly (PACE)
is a comprehensive array of community-based and institutional services for
frail older people (living in a specific catchment area) who would qualify
for nursing facility placement.
Long-term care services also offer institutional nursing care to
Medicaid recipients whose medical conditions require the skills of a
licensed nurse on a regular basis:
- Nursing Facility Program-total medical, nursing, and
psychosocial needs of each consumer, including room and board, social
services, over-the-counter drugs (prescription drugs being covered
through the Medicaid Vendor Drug program), medical supplies and
equipment, and personal needs items. Nursing facilities served
approximately 65,200 consumers per month in FY 2003.
- Rehabilitative Services-physical, occupational, and speech
therapy for eligible nursing facility consumers who do not have
Medicare coverage for these therapies. Rehabilitative services for
persons outside nursing facilities are provided by other agencies.
- Medicaid Swing Bed Program-allows participating rural
hospitals to use their beds interchangeably to provide acute hospital
and long-term nursing facility care to Medicaid recipients, when no
Medicaid beds are available in skilled nursing facilities in the same
geographic area.
- Emergency Dental Services-reimbursement funding for emergency
dental services to Medicaid consumers in nursing facilities.
- Specialized Services-physical, occupational, and speech
therapy for Medicaid consumers determined in the Pre-admission
Screening and Annual Resident Review (PASARR) process to need these
services.
Target Population
Long-term care services are provided to people of all ages who meet
financial eligibility requirements and have medical and/or functional
needs for care on an on-going basis.
Nursing facility services are available to people who need the medical
care of a licensed nurse on a regular basis. Waiver services are generally
targeted to people who have a medical need for nursing facility services,
who are at risk of institutionalization in a nursing facility, and who
prefer to receive services in the community. Non-waiver community care
services are available to people whose disabilities limit their ability to
care for themselves and who may be at risk of needing nursing facility
services.
Some services have age limits; for example, CBA serves adults only, and
MDCP serves children only. Most services are available to all age groups.
Since disabilities and serious medical conditions become more common with
age, long-term care recipients are predominantly older people, with many
being very old (persons ages 80 and over). Younger people, especially
those under 65, are more likely to receive waiver or other community-based
services. Older persons, especially those past age 85, are more likely to
receive nursing facility services.
Some services are targeted to specific disabilities or medical
conditions, such as the deaf-blind waiver, but most serve persons with a
wide range of disabilities and conditions.
Long-term care services are available to people with limited income and
resources. Some people are eligible for Medicaid under Supplementary
Security Income (SSI) rules, while others have incomes up to three times
the SSI amount, with limited assets. Asset limits for services funded by
GR and Social Services Block Grant are higher than those funded by
Medicaid.
Mental Retardation Services
Service Description
The Department offers community-based services for persons diagnosed with
mental retardation or related conditions, who meet diagnostic and
functional need criteria. These services may be provided through GR
appropriations or Medicaid funds. All MR services are accessed through a
local MRA. Services are described as follows:
- Eligibility Determination-an assessment or the endorsement of
an assessment conducted to determine whether a person has mental
retardation, and whether a person is a member of the MR priority
population.
- Service Coordination-assistance in accessing medical, social,
educational, and other services and supports to help consumers achieve
the quality of life and community participation they want.
- Support Services-assistance for consumers not receiving
residential services. These services include supported home living,
respite services (in or out of home), employment assistance,
individualized competitive employment, specialized therapies (support
services provided by a licensed or certified professional such as
psychology, nursing, social work, occupational therapy, physical
therapy, speech, or behavioral health services), and family support
services (to help preserve the family unit and prevent or limit
out-of-home placement of an individual).
- In-Home and Family Support Services-grant benefits to persons
who have mental retardation to support their living independently in
the community and to prevent institutionalization. The consumer may
use the benefits to purchase special equipment, medical supplies, and
adaptive aids and also to modify the home and automobile to make them
accessible and usable.
- Day Training Services-services provided away from an
individual's home to help the individual develop and refine skills
necessary to live and work in the community. This category includes
vocational training and site-based habilitation services.
- Residential Services-24-hour services provided to a consumer
with mental retardation who does not live independently or with their
natural family. There are three types of GR-funded residential
services: family living, residential living, and contracted
specialized residences.
Medicaid waiver programs are community-based services to serve people
in their communities, rather than in institutions. The programs are
described as follows:
- Home and Community-Based Services (HCS) Waiver Program-comprehensive,
community-based services and supports to eligible people with mental
retardation, as an alternative to the ICF/MR program. Covered services
include adaptive aids, case management, counseling and therapies
(includes audiology, speech/language pathology, occupational therapy,
physical therapy, dietary services, social work, and psychology),
minor home modifications, dental treatment, nursing, residential
assistance, respite, day habilitation, and supported employment. In FY
2003, this program served about 8,000 consumers.
- Texas Home Living (TxHmL) Waiver Program-a recently approved
waiver providing limited supports to help eligible consumers stay in
their own or family homes, participating in family and community life.
The program helps people avoid placement in the ICF/MR program.
Services include community support, day habilitation, employment
assistance, supported employment, respite, nursing, behavioral
support, specialized therapies (includes physical therapy,
occupational therapy, audiology, speech/language pathology, and
dietary), minor home modifications, adaptive aids, and dental
treatment.
The ICF/MR program provides residential and habilitative services,
skills training, medical services, and adjunctive therapies with 24-hour
supervision and coordination of the individual program plan. The programs
are described as follows:
- Community ICF/MR Program-residential environments ranging
from six beds to several hundred beds. Each ICF/MR, whether publicly
or privately operated, holds an individual contract with the
Department. The community ICFs/MR served almost 7,700 consumers during
FY 2003.
- State Mental Retardation Facilities (SMRFs)-24-hour
residential treatment and training services for persons with mental
retardation. There are 13 facilities in Texas, and each is certified
as an ICF/MR. The SMRFs serve individuals with severe or profound
mental retardation and those individuals with mental retardation who
are medically fragile or who have behavioral problems. Major services
provided include: 24-hour residential care and support; comprehensive
behavioral treatment services; comprehensive health care services;
occupational, physical and speech therapies; personal life skills
training; paid work programs; and services to maintain connections
between consumers and their families and/or natural support systems.
The SMRFs served approximately 5,000 consumers in FY 2003.
Target Population
The priority population for MR services consists of individuals who meet
one or more of the following descriptions:
- People with mental retardation, as defined by Texas Health and
Safety Code Section 591.003;
- People with pervasive developmental disorders, including autism, as
defined in the current edition of the Diagnostic and Statistical
Manual;
- People with related conditions who are eligible for services in
Medicaid programs; or
- Nursing facility residents who are eligible for specialized services
for mental retardation or a related condition pursuant to Section
1919(e)(7) of the Social Security Act.
- Children who are eligible for services from the Division of Early
Childhood Intervention Services, now a part of DARS.
The determinations of mental retardation, pervasive developmental
disorders, and related conditions must be made through the use of
assessments and evaluations performed by qualified professionals.
Admission to MR services is based on an individual's need and eligibility
for a particular service, in accordance with rules and policy of the
Department.
The Texas Mental Health and Mental Retardation Act requires that the
Department identify priority populations and the minimum array of services
necessary to address their needs. Table 6.2 reflects the growth of the MR
population and of those qualifying as "most in need." Between
2005 and 2009, the number of individuals with mental retardation is
expected to grow from 613,955 to 650,708. For individuals qualifying as
"most in need"-the Department's priority population-the growth
is projected to climb from 107,948 in 2005 to 114,410 in 2009.
Table 6.2
Projected Growth of Mental Retardation Priority Population
| |
FY 2005 |
FY 2006 |
FY 2007 |
FY 2008 |
FY 2009 |
| MR Population |
613,955 |
623,048 |
632,198 |
641,413 |
650,708 |
| Priority Population |
107,948 |
109,547 |
111,156 |
112,776 |
114,410 |
Table 6.2: U.S. Census Bureau, Census 2000, Public Use Microdata
Sample (PUMS), Texas State Data Center, Population Growth Scenario 0.5,
2004.
DADS Goal 1 Trends and Initiatives
Demographic Changes in the Aging Population
Growth
The national growth of the aging population has been well documented. Baby
boomers will begin to reach age 65 in the year 2011 and reach the very
vulnerable age of 85 in 2031. The number of persons age 65 and over is
projected by the U.S. Bureau of Census (1996) to reach 40 million in 2010
and 80 million in 2050. Currently, 12.4 percent of the general population,
or about one in eight people, is age 65 and over. By 2030, the age 65 and
over population is expected to account for 20 percent of the total
population. The minority population among those ages 65 and over is
expected to grow significantly and account for 26.4 percent of the older
population in 2030, up from about 17 percent in 2000.
In Texas, the number of people age 65 and over is projected to be about
2.2 million in 2005. By 2010, their numbers are projected to top 2.5
million, and will double to about 5.2 million by the year 2030. Growth
among the minority population age 65 and over in Texas appears to outpace
the national projections. In 2005, the minority population among persons
age 65 and over is projected to be about 30 percent. By the year 2040, the
minority population will account for 56 percent of the older population,
with Hispanics comprising over half the older minority population.
Growth of the Very Old
The aging of the population has created an additional category of the
older old, meaning people age 85 and over. Among the aging, this is the
fastest-growing segment of the population. There were about 4.6 million
people age 85 and over in 2002. Their number is expected to double to 9.6
million by 2030. By 2040, their number is expected to grow to 14 million,
and by 2050, if the highest projection series holds true, the 85 and over
population could approach 31 million.
In Texas, the 85 and over population is expected to exceed 255,000 in
2005. By 2010, this population is projected to grow to more than 294,000.
Projections for the year 2030 show the 85 and over population at almost
500,000, climbing to more than 831,000 by 2040. Since the older old often
have severe, chronic health problems which demand special attention, the
rapid growth of this segment has significant implications for long-term
care services(1).
Possible Improvements in Disability Status(2)
The age-adjusted disability rates among older persons appear to be
declining. That is, a typical 75-year-old today is less likely to be
impaired than was a typical 75-year-old of 15 years ago. In particular,
older persons are less likely to be dependent in the Instrumental
Activities of Daily Living, such as preparing meals, using the telephone,
and managing money. Technological improvements have supported this trend:
help with money management has significantly declined with the adoption of
direct deposit and automatic bill pay options; help with meal preparation
has decreased as availability of prepackaged meals and wider use of
microwave ovens have increased; and help with telephone use has dropped
since amplifying devices and one-touch speed dialing have become common.
However, the reduction in disability status through technological
improvement does not necessarily imply better health.
Possible Shifts in the Sex Ratio
In the last few years, life expectancy for men has been increasing more
rapidly than for women, narrowing the gap between the two groups. Over
time, this trend may decrease the percentage of older persons who are
living alone. Since very old persons living alone are among those most
vulnerable, increased life expectancy for men may also mitigate the demand
for services(4).
Stress on the Informal System
Current estimates indicate that 25 percent of American families are
involved in elder/parent care in some way, and nearly two-thirds of the
baby boom generation will be caring for aging parents in the next ten
years. National surveys indicate that relatives care for four out of five
older people who have a disability. This informal system of care giving
has been valued at $257 billion annually-more than double the national
expenditure for nursing facility and paid home care combined(5).
Recently, this informal system is experiencing stress as the pool of
family caregivers shrinks. In 1990, there were 11 potential caregivers for
each person needing care, but by 2050, this ratio is expected to fall to
four to one. The large, extended families of past generations are less
common, and greater mobility among adult children often means that care
giving responsibilities for aging parents fall to one child. These
caregivers likely are parents themselves who are active in the work force;
they are sometimes referred to as the "sandwich generation."
Almost 52 percent of caregivers have some kind of workplace problem as a
result of their care giving, and estimates for business losses range
between $11 and $29 billion annually due to the employees' needs to care
for loved ones age 50 and over(7 8).
Demographic Changes in the Non-Older Person Population with
Disabilities
Recent studies indicate that the disability rate is rising among
working-age adults (ages 21-64). While reasons for the rise are unclear,
some possible influences include improved trauma survival rates, more
liberal program or insurance benefits, and increased rates of obesity. The
fastest growing causes of disability among non-older persons are diabetes
and musculoskeletal problems, conditions that are associated with obesity(9).
Weight has a dramatic effect on a person's ability to manage five basic
activities of daily living: bathing, eating, dressing, walking across a
room, and getting in or out of bed. Moderate obesity for men is associated
with a 50 percent increased probability of having limitations on these
abilities, and severe obesity is associated with a 300 percent increased
probability. For women, the effects are even larger(10).
Increased prevalence of all disabilities will inevitably increase the
demand for long-term care services, especially community-based and
client-managed services.
Demographic Changes in the Population with Mental Retardation
Growth
About 2.7 percent of the general population has mental retardation, and
the number of individuals with mental retardation increases as the general
population increases. The projected growth of the population with mental
retardation as identified in Table 6.2 reflects a six percent increase
from 2005 to 2009. The projected growth in the priority population between
2005 and 2009 reflects this same six percent increase.
Aging(11)
With improved health care and health care technology, the life expectancy
for individuals with mental retardation has increased from 19 years in the
1930s to 66 years by 1993. The average age at death for the general
population in 1993 was 70 years. Experts observe that with continued
improvement in their health status, individuals with mental
retardation-particularly those without severe impairments-could be
expected to have a lifespan equal to that of the general population. As
people with mental retardation live longer, they will require services and
supports for longer periods of time, directly impacting the finite
capacities of state service delivery systems.
Stress on the Informal System(12)
The aging of the general population directly influences demand for
developmental disabilities services, because the majority of people with
developmental disabilities in the U.S. currently live with family
caregivers. Analysis of FY 2000 data reveals that 61 percent (2.79
million) of the 4.56 million persons with developmental disabilities in
the U.S. population were receiving residential care from family
caregivers. Further analysis of the 2.79 million individuals who receive
care from family caregivers revealed that 25 percent were living with
family caregivers age 60 and over, and an additional 35 percent were in
"households of middle-aged caregivers (41-59 years) for whom
transition issues are near-term considerations." The remaining 40
percent were living with caregivers less than 41 years of age. This
informal system of residential care served about six times the number of
persons served by the formal, out-of-home residential care system (460,455
persons). As these caregivers age, they are less able to provide care, and
formal living arrangements must be established to support their relatives
with disabilities.
Impact on Services and Interest Lists
Long-Term Care Services
Since 1980, the overall number of persons receiving nursing facility
services under Medicaid in Texas has changed very little, but the number
of persons over 85, those most at risk of need for nursing facility care,
has more than doubled. The nursing facility program is a Medicaid
entitlement program, and as such can grow in response to demand without
the need for waiting lists. However, the relative stability of the nursing
facility population numbers reflect that far more Texans now receive care
in the community than receive nursing facility care.
The demand for community-based care in Texas is not being fully met,
and the population needing services continues to grow. Some community care
programs such as the Primary Home Care, Community Attendant Services, and
Day Activity and Health Services are Medicaid entitlement programs that
can grow in response to demand. Medicaid waiver programs, however, are not
entitlement programs and have limited capacities. Individuals expressing
interest in these programs far exceed the programs' capacities. The
interest list for the CBA waiver at the end of the second quarter of FY
2004 included 63,232 individuals, and the list for the CLASS waiver
included 11,072 individuals. Interest lists also exist for other community
long-term care programs funded with Social Services Block Grant or GR
funds, such as home-delivered meals and Emergency Response services.
Long-term care staff contact individuals on the interest list each year
to confirm their desire for services. People on the interest list are not
assessed until there is an opening, and about half of those assessed do
not qualify for services. Senate Bill 285, 78th Legislature, Regular
Session, 2003, now calls on the Department to forecast openings likely to
become available during the next fiscal quarter, and to contact the
individuals on the waiting list at least 30 days before the opening, to
begin eligibility determination.
In addition to the demand for traditional, community-based services
already discussed, there is a trend away from dependence on services
provided by licensed agencies, in favor of personal attendants hired,
trained, and supervised by the individual needing services. A small but
growing number of people with disabilities prefer to manage their own
services. The growing numbers of younger people with disabilities in the
long-term care population tend to reinforce the move toward
community-based services and the demand for client-managed services.
Mental Retardation Services
As with long-term care services, more people need mental retardation/
developmental disabilities services and supports than the systems in most
states can provide. Since the 1970s, many states have reduced their
reliance on institutional facilities and have developed community
residential settings, including group homes, foster care, and supported
living options(13). This national trend holds
true for Texas: the demand for institutional services is decreasing while
the demand for community services is increasing. Between 1980 and 2004,
the number of people living in large, state-operated facilities serving
people with mental retardation has dropped from 10,320 to 4,978. In a
residential survey(14) completed for FY 2002,
of the 20,042 persons served in Texas' public and private institutional
facilities, 36 percent (7,320) were served in settings with 16 or more
persons. Texas served 63.47 percent of persons receiving residential
services in small residential settings (1-15 beds). The demand for home-
and community-based services is not limited strictly to residential
services, but includes all services and supports available to persons with
mental retardation, and it has created a gap between service needs and
what the current system can provide. This gap is the waiting list for MR
services.
Texas is not alone in facing this issue; there are waiting lists(15)
in every state. Gary A. Smith summarized the waiting list phenomenon in
the National Association of State Directors of Developmental Disability
Services Special Studies Initiative Report on waiting lists. He identified
seven factors that account for the high rate of demand for long-term
services and supports. These factors include:
- Increasing longevity of people with developmental disabilities;
- Demographic impact of the baby boom generation;
- Redirected demand (from nursing facilities to community-based care)
on the developmental disabilities system;
- Broadening of eligibility criteria in some states;
- Higher family expectations concerning services and supports;
- The increased demand that occurs when people become aware that new
services have been funded; and
- Changing economic demands on family.
Demographic trends clearly suggest that as baby boomers age, waiting
lists will increase markedly, unless a concerted state/federal effort is
mounted to address this issue.
Waiting lists initiatives in the states have generally involved
expanding family support to prevent or delay the need for institutional
placements(15). States have also been
obtaining new or reallocated resources from the following sources:
institutions, ICF/MR conversion to Medicaid Waiver programs, refinancing
of state general revenue with Medicaid funding, capping reimbursement for
existing programs, and seeking additional Medicaid funding.
In Texas, at the conclusion of the second quarter of FY 2004, there
were 25,560 individuals waiting for MR services. Of the total number
waiting, 24,502 (96 percent) were waiting for services from the Medicaid
HCS Waiver. Interim GR-funded services are provided to 53 percent of the
waiver waiting list group. Staff of the local MR authorities contact
individuals on the waiting list annually to confirm they still need and
want waiver services.
Older Americans Act
The OAA Amendments of 2000 (Public Law 106-501) extend the Act's
programs through FY 2005 and make several changes, including:
- Creation of the National Family Caregiver Support Program;
- Creation of new targeting requirements for rural elders;
- Increased budget authorization for certain service categories;
- Consolidation of funding for certain services;
- Creation of new cost-sharing provisions;
- Expanded authority for categorical transfers and state waivers;
- Consolidation of reporting and reimbursement process for meals under
the USDA; and
- Addition of three new areas for research, training, and
demonstration projects.
Permanency Planning
Permanency Planning is a philosophy and planning process that focuses
on the outcome of family support for children with developmental
disabilities. This is achieved by facilitating a permanent living
arrangement for a child with an enduring and nurturing parental
relationship. Senate Bill 368, 77th Legislature, Regular Session, 2001,
made numerous changes to state law regarding permanency planning for
individuals with developmental disabilities.
This bill extends the age range to 22 years for permanency planning for
each individual with a developmental disability who resides in an
institution or for whom institutional placement is sought. The bill also
expands the definition of institution to include not only ICFs/MR, but
also group homes operated by DFPS, nursing facilities, DFPS-licensed
institutions for people with mental retardation, and foster homes. The
legislation mandates that admission of an individual under age 22 to an
institution is considered temporary and may be initially approved for only
six months. It outlines a review and monitoring system involving the
Commissioner or designee for approval of admission or extension. It also
provides for the appointment of a volunteer advocate to assist in the
permanency planning process. Lastly, it requires that the names of all
individuals under age 22 admitted to an institution be placed on the
appropriate waiver waiting list.
During FY 2003, the Department ensured that every child with a
developmental disability in a nursing facility was identified and
re-evaluated to determine whether the child could return to a home
setting. Children with mental retardation were referred for MR services.
Children with other developmental disabilities were referred to community
care programs for services.
Helping Nursing Facility Residents Return to the Community
A group of initiatives and legislative changes are enabling people who
receive nursing facility care to return to the community more easily.
Money Follows the Client
Medicaid clients in nursing facilities who wish to relocate to the
community can do so more easily. The funding that had been used to provide
their nursing facility services is transferred to the community program.
The interest list is not affected.
Housing Voucher Program
This program, created in May 2002, helps former nursing home residents who
are transitioning to the community gain access to affordable, accessible
housing. The program is a collaborative effort among DADS, HHSC, the Texas
Department of Housing and Community Affairs, and the U.S. Department of
Housing and Urban Development.
Transition to Life in the Community Grants
These grants target people moving from nursing facilities into the
community, providing one-time assistance funds for initial rent and
utility deposits, other relocation-related expenses, and household items
needed to re-establish residence in communities. In FY 2005, these grants
will become part of the CBA waiver, rather than a separate program.
Community Awareness and Relocation Services (CARS)
This pilot program began in June 2002, serving Austin, Corpus Christi,
Crockett, Houston, and Temple. The CARS contractors raise community
awareness about available community alternatives, care and support
options, and accessing services. The relocation activities include
identifying nursing facility residents who are interested in returning to
the community, assessing their transition needs, and helping them with the
transition process. Services are now available on a wider geographic
basis.
New Freedom Initiative
President Bush's Executive Order 13217: Community-Based Alternatives for
Individuals with Disabilities, also known as the New Freedom Initiative,
was issued on June 18, 2001. The order directed a government-wide review
of federal policies to identify ways to allow people with disabilities to
live in and participate fully in their local communities. The 1999 Supreme
Court ruling in the Olmstead case and this Executive Order have committed
the nation to helping people with disabilities to overcome barriers to
community living.
In March, 2004, a progress report on the New Freedom Initiative was
published. The report summarizes the actions federal agencies have taken
in the following areas:
- Health care structure and financing;
- Housing;
- Personal assistance, direct care services, and community workers;
- Caregiver and family support;
- Transportation;
- Employment;
- Education;
- Access to technology;
- Accountability and legal compliance;
- Public awareness, outreach, and partnerships;
- Income supports;
- Gathering, assessment, and use of data; and
- Cross-agency collaboration and coordination.
Federal agencies involved in carrying out the Executive Order developed
agency-specific plans to implement actions to enhance community
integration and remove federal barriers to integrating people with
disabilities into the fabric of community life. This progress report also
begins identifying the "next steps" in fulfilling the vision
outlined in the New Freedom Initiative.
Increased Recipient Control of Services
Persons receiving personal attendant services in the community may opt
to select, train, hire, and manage their own attendants. Few have chosen
to exercise this option of complete control and responsibility. With the
help of federal funding, the Department is developing a hybrid service
management option that allows consumers to select, train, and supervise
their attendants but leaves fiscal, personnel, and backup responsibilities
with a provider agency.
Senate Bill 367
Senate Bill 367, 77th Legislature, Regular Session, 2001 requires that
consumers with mental retardation, their legally authorized
representatives (LARs), and, if the LARs are not family members, at least
one family member, each be provided information regarding all care and
support options available to the consumer. The bill also codified the
Living Options process to help make decisions about care-setting options.
The bill created an HHSC advisory committee, named the Interagency Task
Force on Ensuring Appropriate Care Settings for Persons with Disabilities,
to guide the development of the Texas Promoting Independence
Plan,
discussed above. Under H.B. 2292, the task force was preserved and renamed
the Promoting Independence Advisory Committee. Most of the committee
members represent a variety of stakeholder groups, including consumer and
family interests. The committee is charged with advising HHSC about
achieving the objectives of the Promoting Independence Initiative.
Senate Bill 367 also requires a memorandum of understanding (MOU)
between the legacy DHS and the legacy Department of Mental Health and
Mental Retardation for a pilot study in several locations to address the
coordination of services for people with mental illness or mental
retardation who want to transition to the community from nursing
facilities. The program is now being expanded statewide under DADS.
DADS Goal 2: Regulatory and Licensing Services
Provide licensing, certification, and contract enrollment services,
as well as financial monitoring and complaint investigation, to ensure
that residential facilities, home and community support services agencies,
and individuals providing services in facilities or home settings comply
with state and federal standards and that clients receive high-quality
services and are protected from abuse, neglect, and exploitation.
The Division of Regulatory Services handles the Department's oversight,
administrative, and regulatory responsibilities for long-term care
services to about 305,400 older persons, people with disabilities, and
people with mental retardation. In FY 2002, about 66,800 consumers lived
in nursing facilities, and about 218,000 consumers received disability
services in the community. Additionally, there were over 5,400 individuals
receiving services in state MR facilities, over 8,100 people in community
ICF/MR programs, and more than 6,800 individuals participating in MR
waiver services.
By statute, all long-term care facilities meeting the definitions of
nursing homes, assisted living facilities, adult day care facilities, and
privately owned ICFs/MR must be licensed and must comply with all
licensure rules to operate in Texas. Publicly operated ICFs/MR (state or
community MH/MR centers) and skilled hospital units must also be certified
to participate in Medicare and/or Medicaid. Home and Community Support
Service Agencies (HCSSAs) also fall under the Department's licensing and
certification review functions. In FY 2003, the Department regulated 1,176
nursing facilities, 1,385 assisted living facilities, 2,597 HCSSAs, 907
ICFs/MR, and 404 Adult Day Care facilities.
Waiver program providers are reviewed and certified for compliance with
the program certification principles. The Department conducts an annual,
on-site certification review of the program provider to evaluate
compliance. Based on the review, corrective actions may be required and
sanctions imposed.
The Quality Management staff oversee compliance of local authorities
with the MR performance contract requirements. These requirements include
responsibilities for planning, policy development, coordination, resource
development and allocation, and oversight of MR services in the most
appropriate and available setting to meet individual needs in a local
service area.
The regulatory division also provides federal certification for
facilities participating in the Medicaid and Medicare programs. Provider
agencies served through the program include those that provide licensed
home health services, licensed and certified home health services, home
dialysis, hospice services, and personal assistance services. House Bill
2292 requires the Department to explore using the Joint Commission on
Accreditation of Healthcare Organizations standards and processes for
regulatory functions.
The regulatory division is responsible for more than facility surveys.
When a provider applies for licensure, the division reviews the
applicant's history as a provider, obtaining detailed information on
operators, owners, and other controlling persons. The division assesses
all this information and approves or denies the application accordingly.
The division also pursues enforcement actions against facilities cited for
non-compliance with regulations, manages Medicaid contracts, and provides
information to the public as appropriate.
The Department operates four credentialing programs that license,
certify, permit, and monitor individuals to determine whether they can be
employed in facilities and agencies regulated by the Department. These
programs are as follows:
- Nursing Facility Administrator Licensing and Investigations
Program-responsible for licensing and continuing education
activities; imposing and monitoring sanctions; providing due process
considerations; and developing educational, training and testing
curricula. Investigating complaints or referrals, coordinating
sanction recommendations and other licensure activities with the
Governor-appointed Nursing Facility Administrators Advisory Committee.
In FY 2002 there were 2,227 licensed nursing facility administrators.
- Nurse Aide Registry and Nurse Aide Training and Competency
Evaluation Program-responsible for nurse aide certification and
sanction activities; approving or renewing Nurse Aide Training and
Competency Evaluation Programs (NATCEP); withdrawing NATCEP approval,
and providing due process considerations and a determination of nurse
aide employability in nursing facilities regulated by the Department
via the Nurse Aide Registry. In FY 2002 there were 95,238 certified
nurse aides.
- Employee Misconduct Registry-responsible for providing due
process considerations and a determination on employability of
unlicensed staff in facilities and agencies regulated by the
Department (including HCSSAs).
- Medication Aide Program-responsible for medication aide
permitting and continuing education activities, issuance, and renewal;
imposing and monitoring of sanctions; providing due process
considerations; approving and monitoring of medication aide training
programs in educational institutions; developing educational,
training, and testing curricula, and coordinating and administering
examinations. In FY 2002, there were 6,564 permitted medication aides.
DADS Goal 2 Trends and Intiatives
Like other states, Texas faces many challenges in assuring and
improving quality in its long-term care programs. Ensuring the health and
welfare of program participants in institutional care is typically
accomplished by a centralized oversight system, with medical, behavioral,
and direct care staff readily available on-site.
Quality Outreach
Created through Senate Bill 1839, 77th Texas Legislature, Regular
Session, 2001, this technical assistance program is a service for
providers of long-term care. The program consists of three components that
provide a non-regulatory framework for fostering improvements in the
quality of resident services.
- Quality Monitoring-provides problem-oriented technical
assistance by monitors, who are nurses, pharmacists, and dieticians,
to long-term care facility staff. The program uses a systems-analysis
approach to identify and address the causes of lapses in the use of
evidence-based practices. Through unannounced visits, monitors perform
structured resident assessments to identify system-level lapses in the
application of best practices to resident assessment, care planning,
and care delivery.
- Joint Training-provides opportunities for regulators and
providers of long-term care services to participate in an educational
process that addresses both clinical knowledge and knowledge of
regulations to foster a common and shared understanding. The emphasis
of this training is on the care issues that lead to the 10 most
frequently cited deficiencies in long-term care.
- Long-Term Care Facility/Surveyor Liaison-provides a conduit
for communication between facility staff and survey team members to
resolve medical issues and improve nursing performance in long-term
care facilities. These staff members jointly maintain medical/nursing
knowledge regarding state and federal facility surveys. They also
perform advanced clinical/nursing reviews of certification surveys,
licensure inspections, and investigations conducted in long-term care
facilities to determine medical compliance with state/federal
requirements and protocols, to ensure clients receive optimal care.
A collaborative relationship exists with the LTC Ombudsman Program and
advocacy groups to promote quality initiatives. In addition, Texas
contracts with the Texas Medical Foundation to assist providers in quality
improvement efforts. The last 24 months of work toward quality improvement
in nursing facilities has led to rapid reduction in restraint use, marked
improvement in the evaluation of residents for whom indwelling catheters
are used, and modest improvement in providing needed toileting assistance.
The Department has also begun to work with long-term care providers toward
improvements in pain assessment, pain management, fall risk management,
resident and staff immunizations, dietary care planning, preventing
dehydration, and improving advance care planning.
Redesign of Quality Assurance/Quality Improvement System
Community-based service programs face a major challenge of ensuring the
health and welfare of all participants living in the community while
preserving their privacy and right to make choices. To enhance quality
management, the Department strives for consistency across the state while
balancing the needs of local community participants, families, and other
stakeholders in a variety of supports and services.
To test the capability of this system, the Department is redesigning and
improving the information-gathering system to integrate existing waiver
quality assurance and quality improvement reporting mechanisms into a
comprehensive data collection system and process. The HCBS Quality
Framework-a quality initiative of the Federal Centers for Medicare and
Medicaid Services (CMS)-is being used as a guide in this process. This
proposed system will ensure an accountable use of public resources and a
balance between personal outcomes/flexible supports and regulatory
requirements to improve the quality of the MR waiver programs.
To facilitate the proposed system redesign, the Department applied for
and was awarded a Real Choice Systems Change Grant for quality
assurance/quality improvement (QA/QI) by CMS. The grant will allow DADS
to:
- Involve stakeholders in the development and implementation of the
project;
- Research and develop a methodology to measure individual consumer
experiences in MR waiver programs;
- Develop an automated critical incident reporting process to capture
information identified by the QA/QI Task Force as necessary to ensure
health and welfare of participants; and
- Purchase expertise to develop a centralized information-gathering
system to compile results obtained through newly created sources of
data (for example, participant experiences and critical incidents) and
existing sources of data (for example, survey/certification review
results).
System reports will be accessible to waiver participants and their
legally authorized representatives, program providers, and MR services
staff. A centralized information-gathering system will help disclose
opportunities for quality improvement across the waiver service system,
resulting in a system that will:
- Focus on the outcomes of services;
- Ensure health, safety and rights protection; and
- Ensure, through performance measures, that local authorities and
program providers are in compliance with contracts and applicable
rules and laws.
<<back to top>>
This section represents an evaluation of the key internal factors that
influence DADS. Below is a discussion of the agency's internal processes
and operations, and its perceived strengths and challenges.
DADS Internal Processes
As previously noted, H.B. 2292 consolidates all mental retardation
services from the TDMHMR, the community care and nursing home services of
the DHS, and the aging services of the TDoA into DADS. The Department is
scheduled for integrated operations September 1, 2004 (also known as DADS
Day One). In order to achieve this goal, and to meet the many changes
required by H.B. 2292, a DADS Program Management Office (PMO) was
established to support the development of the new organization in
cooperation with the executive leadership of DADS.
To facilitate the planning for a new department and to ensure DADS is
operational on September 1, 2004, several DADS Day One workgroups have
been initiated. These workgroups are comprised of all levels of staff from
the three legacy agencies. This cross-representation of staff, coupled
with the development of specific workgroup tools, allows for the
development of the business plan and identification of best practices.
These workgroups are performing detailed analyses of workflow and
processes in the various current programs, business operations, and
locations among the three agencies. From this inventory, the workgroups
will identify:
- Current successful business processes DADS can leverage;
- Redundancies in effort and/or staff; and
- Inefficient processes.
The workgroups have been divided into two overall categories: tasks and
organizational workgroups:
- The tasks workgroups are responsible for issues impacting all
organizational areas in DADS (for example, websites, asset transfers
and relocation, and reporting). These groups are charged with
developing coordinated, streamlined, and efficient processes for the
agency.
- The organizational workgroups were developed to mirror the approved,
high-level organizational structure for DADS. These workgroups are
charged with recommending an operational design and the associated
processes and procedures to ensure uninterrupted services (despite
current differences in legacy agency functions) and to improve overall
efficiency and effectiveness.
In addition to these workgroups' activities, each legacy agency is
continuing to track and monitor requirements for H.B. 2292. Implementation
goals and strategies are in place to ensure that nothing is overlooked.
Furthermore, rules, policies, and procedures for the new agency are being
identified or written, and then used in the process of implementation and
in preparing subsequent reports on that implementation.
DADS Internal Operations
The high-level organizational structure (Commissioner, Deputy
Commissioner, Assistant Commissioners, and Departmental Division levels)
has been developed and approved in a manner consistent with the conceptual
outline in the H.B. 2292 Transition Plan. The unit and subunit structures
below the Division level will be developed by the organizational
workgroups through their processes. The local and regional structures for
departmental presence and service delivery will also be determined through
these workgroups.
The departmental PMO and DADS executive team are active participants in
developing and implementing communication plans to ensure
internal/external stakeholder involvement and in identifying and
mitigating risks and issues during the planning and integration phases of
the transition process.
Within the transition process, opportunities exist to consolidate
aging, mental retardation, and disability programs and services to create
a true continuum of services within a single agency. Additional
opportunities will arise to combine similar programs operating
concurrently in the legacy agencies, and to simplify and streamline access
to and administration of programs, thus leading to greater efficiencies
and improvements in service delivery.
DADS Internal Strengths and Challenges
However, within this changing environment, it is sometimes challenging
to coordinate and disseminate timely and accurate information to the
public about decisions on regional structure, where and how services are
available, and how to access services and/or program administration.
Funding streams and the associated requirements that have been developed
and nurtured by the legacy agencies must also be carefully tracked to
ensure their successful migration to DADS.
Given the magnitude of change in creating a new department from three
existing agencies, confusion and uncertainty are bound to surface. Issues
surrounding the relocation of staff, unknown administration structures,
staff morale, and job insecurity are being addressed by a change
management strategy that includes the following elements.
Cultural Change
Internal change consultants working with the DADS workgroups will create
change management plans to systematically and effectively manage the
changes related to consolidating programs, services, and employees. The
goal of each change plan is to ensure DADS staff members can perform well
enough so DADS may fully realize its outcomes and goals.
Change management initiatives, including orientation, training, and
communication strategies, are planned and will be implemented throughout
the transformation process to help employees make a smooth transition to
the new DADS organization and new culture.
Communications
A communications roadmap has been developed to ensure consistent and
timely communications with all internal/external stakeholders throughout
the transformation. For internal communications, an e-newsletter, DADS
direct, is issued on a regular basis. DADS direct includes transformation
and consolidation news from the Commissioner, an update relating to
transformation activities, and an overview of DADS programs and services.
DADS talk is a newsletter for external communication that addresses these
same issues.
Meetings with employees from each of the legacy agencies are scheduled
throughout the transformation. These informal, open forums offer employees
the opportunity to get to know DADS executive team members, receive the
latest transformation information, and ask questions about transformation
and consolidation activities.
Knowledge Transfer
Retirement incentives, combined with the uncertainty that accompanies
change, have resulted in the loss of a number of knowledgeable and
experienced staff. This will continue to be an increasing challenge in the
coming months, and it threatens the maintenance of on-going operations and
services of the legacy agencies as well as the transformation to DADS.
A mechanism has been built into the DADS Day One workgroup process to
identify and mitigate the impact created from knowledge gaps.
Executive leadership plans on-going, collaborative efforts to balance
the preparation for the upcoming legislative session with the competing
priorities of maintaining current operations, preparing for DADS Day One,
and identifying opportunities for optimization. In the midst of this
tremendous change, the key to success is maintaining best practices and
quality services while minimizing the impact to consumers.
<<back to top>>
- The following priorities express the emphasis that DADS will employ
to meet agency goals and fulfill the agency mission:
- DADS will implement comprehensive, outcome-based quality assurance
and quality improvement systems based on legacy agency quality
initiatives and systems.
- DADS will protect and assure the health, safety and well-being of
individuals in state regulated and state operated services.
- DADS will emphasize consumer choice and consumer control in the
array of services offered, and will encourage single points of local
access and the concept of "no wrong door" to these services.
- DADS will focus on best practices within the continuum of services
to reduce the amount of time people wait for services.
- DADS will advance the objectives of the Older Americans Act
including the Aging Texas Well program to ensure that state and local
communities are preparing for the future.
- DADS will ensure provider accountability for cost-effective services
through a quality-focused contracting system.
<<back to top>>
- TDoA, "Texas Demographics: Older Adults in Texas" (April
2003), http://www.tdoa.state.tx.us/Publications/ResearchReports/
NewDemographicProfile4-03.pdf (accessed April 29, 2004).
- Ibid.
- Brenda Spillman (2003). "Changes in Elderly Disability Rates
and the Implications for Health Care Utilization and Cost," U.S.
Department of Health and Human Services, Urban Institute.
- U.S. Census Bureau, "Aging in the United States: Past, Present
and Future," http://www.census.gov/ipc/prod/97agewc.pdf (accessed
April 27, 2004).
- National Family Caregivers Association, "Family Caregiving
Statistics," http://www.nfcacares.org/NFC2002_stats.html
(accessed April 27, 2004).
- Ibid.
- Christine A. Price. "Aging Families-Series Bulletin #2: The
Sandwich Generation." http://www.hec.ohio-state.edu/famlife/aging/PDFs/
Sandwich%20Generation.final.pdf (accessed April 27, 2004).
- National Family Caregivers Association, "Family Caregiving
Statistics", http://www.nfcacares.org/NFC2002_stats.htm
(accessed April 27, 2004).
- D. N. Lakdawalla, J. Bhattacharya and D. P. Goldman (2004).
"Are the Young Becoming More Disabled? Rates of Disability Appear
to Be on the Rise Among People Ages Eighteen to Fifty-Nine, Fueled by
a Growing Obesity Epidemic." Health Affairs, Vol. 23, No. 1, pp.
168-176.
- R. Sturm, J. Rengel and T. Andreyava (2004). "Increasing
Obesity Rates and Disability Trends." Health Affairs, Vol. 23,
No. 2, pp. 1-7.
- David Braddock. "Disability at the Dawn of the 21st Century and
The State of the States." Washington, DC: American Association on
Mental Retardation, 2002.
- Ibid.
- Rizzolo, M. C., Hemp, R., Braddock, D., & Poneranz-Essley, A.
"The State of the States in Developmental Disabilities." The
University of Colorado, Department of Psychiatry and Coleman Institute
for Cognitive Disabilities. 2004.
- Prouty, R., Smith, G., & Lakin, K. C. (Eds.). "Residential
Services for Persons with Developmental Disabilities: Status and
Trends Through 2002." Minneapolis: University of Minnesota,
Research and Training Center on Community Living, Institute on
Community Integration. 2003.
- Gary A. Smith. "Closing the Gap: Addressing the Needs of People
with Developmental Disabilities Waiting for Supports."
Alexandria, VA: NASDDDS Special Studies Initiative Report. 1999.
- K. Charlie Lakin. "Perspectives. On the Outside Looking In;
Attending to Waiting Lists in Systems of Services for People with
Developmental Disabilities." Mental Retardation, 1998, Vol. 36,
pp. 157-162.
<<back to top>>
<<back to Table of Contents>>
|
