Governor’s Council on Developmental Disabilities

Georgia Advocacy OfficeInstitute on Human Development and

Disability

Marcus Institute

Challenges in DD ServicesOlmstead in GeorgiaMedicaid: EPSDT, Katie Beckett, and WaiversProvider CapacityFamily SupportEducationTransitionEmploymentAging

Departments and ServicesAgency Adult Service Child Service

DCH Independent Care Waiver Program; SOURCE

Medicaid Buy-In

Katie Beckett, CMOs, Peachcare

DHR MRWP waiver programs

Aging Programs

Family Support,

CMS, Babies Can’t Wait

DOE Transition to adult services

K-12 education, special education

DOL Vocational Rehabilitation

DECAL Pre-K Program

DCA Housing, home modifications

History of Olmstead1999 US Supreme Court decision

Plaintiffs Lois Curtis and Elaine Wilson Attorney Sue Jamieson

PlanMulti-agency stakeholder committee (2001-2002)

identified number of people to be transitioned funding needed time frame

Governor Barnes unable to commit to effort No plan formally submitted

Governor Perdue modified the plan with document of intents No mechanism for accountability

Out-of-Home Residential Placements: Georgia 2006

• Georgia ranked 32nd in the percentage of out-of-home placements in settings for 6/fewer persons.

Source: Braddock et. al. (2007, preliminary).

32%

35%

18%

13%

Total: 9,033 Persons

Group homes, foste r homes,

apartments2,916

Supported Liv ing3,202

6 or Fewer Total Including Supported Living: 68%

Nursing facilities1,604

State Institutions 1,201

Private ICFs/M R 16+110 (1%)

Georgia Fiscal Effort for DD Services 1977-2006

Source: Braddock et al. (2007, preliminary)

77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06Fiscal Year

$0.00

$0.50

$1.00

$1.50

$2.00

$2.50

$3.00

$3.50

Spending ($) per $1,000 Personal Income

$2.17 $2.20

$2.00

$1.73

$2.26

$2.42

$0.89 $0.93 $0.97

$1.06

$1.79 $1.82

$1.28 $1.28 $1.03

$0.67

$0.47

$0.60

TotalCommunity ServicesInstitutional Settings

NW Regional 103

Central State 461

SW State 152

Georgia Regional 79 East Central

461

Persons with DD in State Hospitals

Hospital IssuesState Hospitals

Are understaffedHave under-trained employees Have high turnover rates Overuse medications and restraintsLack effective transition plans for people to move outLack capacity to transition people successfully back to

the community

Network Response to OlmsteadHR 1307

5-year plan for funding home and community-based services

Funding package includes transitioning people from institutions

Since 2005, this effort has resulted in 4000 new services, and of those services 304 were for institutional transitions. There have been 114 actual placements.

OCR Complaint

Network Response to OlmsteadReal Choices Systems Change grants

Transition program that builds on model Peer Support Program Direct Support Staff development initiativeMedication Certification Program Improvement in communication policies, procedures in agencies

providing long term care servicesDevelopment of regional access system for MH and DD servicesDevelop uniform individual budgeting mechanismsDesign key features of self-directed service delivery system

Money Follows Person RebalancingGeorgia will move 1347 individuals from nursing homes and large

state institutions with $34,000,000 in funding over 5 years

Challenges in DD ServicesOlmstead in GeorgiaMedicaid: EPSDT, Katie Beckett, and WaiversProvider CapacityFamily SupportEducationTransitionEmploymentAging

EPSDT EnvironmentEligibility:

Constant challenges to eligibility Many categories of Medicaid access, with varying eligibility

criteriaAccess:

Providers discouraged from serving families resulting in service gaps Excessive paperwork Prior authorization process Low reimbursement rates

Coverage Caps and limits to services Certain services excluded from state plan

Katie Beckett/Deeming WaiverState revised level of care criteria

2000 families kicked off Medicaid

Legislature allocated $7.6 million in transitional funding (2006) $5.4M allocated as cash disbursements to

families denied Medicaid $2600 dispersed to each family via a debit card

$2.2M set aside for development of community-based funding mechanism and program

• Support monitoring & evaluation• Habilitation (day, community) • Home Health services, nursing care• Supported employment services• Personal support/supported living• Respite care• Environmental modification; accessibility adaptations; vehicle

adaptations• Specialized medical equipment/supplies• Case management• Residential training & supervision• Personal emergency response system• Consumer directed service delivery option

Services Provided by HCBS Waiver

Source: National Association of State Medicaid Directors (2006).

New Options Waiver (NOW)Focus on day supports, and a comprehensive waiver for

residential and support servicesSupports Intensity Scale: Consumer need is based on

the SIS and services will be individually tailored according to the results of the SIS

Individual Budgets: the SIS will determine within a range how much funding is available to meet person’s identified needs

Choice of Services: Families will have more options for arranging support for their member, or they can remain in the services they have

NOW WaiverFinancial Support Services: Families can choose their

providers and use the fiscal agent to pay the bills for them, including background check, taxes, SS, W-2s, etc

New Services payable under the waiverDental Natural Support Training

Transportation OT, PT, Speech, Nutrition

Behavioral support Community Guide

Network Response to Challenges in Medicaid

Convening stakeholder groups to share information on CMO implementation

Preparing memos and briefs on impact of changes to Medicaid

Communicating with parents to provide information and encourage advocacy

Collecting and analyzing data Informing legislators about impact on familiesLegal action

Challenges in DD ServicesOlmsted in GeorgiaMedicaid: EPSDT, Katie Beckett, and WaiversProvider CapacityFamily SupportEducationTransitionEmploymentAging

Provider Capacity is a Priority

Limited or no choices in rural GeorgiaVariable quality of providersTendency toward congregate settingsHigh turnover in front line workers and support

coordinationBelow average reimbursement ratesNeed a new array of providers with new waivers

Direct Support Community Staff Wages: Below Poverty Level

• The average community direct support wage in Georgia was 24% below the state’s institutional average direct support wage.

All Workers State-Operated Poverty Level Nursing Aides Comm. ID/DD Comm. ID/DD$0

$4

$8

$12

$16

$20

Dollars per Hour

$17.18

$10.50$9.62 $9.18 $8.68

$8.00

GeorgiaU.S.Georgia U.S.Georgia

Direct Support Professionals DevelopmentCollaboration with

MHDDAD Real Choices Systems Change Grant Aging Mental HealthDivision of Adult and Technical EducationGCDD

Standard curriculum offered at 7 technical institutions

Formation of Direct Support Professional Alliance

Network Response to Provider Capacity

Supporting and promoting state efforts to develop provider capacity

Signaling to providers that money will be available for integrated and inclusive home and community –based services

Educating people about services available in the NOW waiver and how to access them

Supporting provider rate increases

Challenges in DD ServicesOlmsted in GeorgiaMedicaid: EPSDT, Katie Beckett, and WaiversProvider CapacityFamily SupportEducationTransitionEmploymentAging

Number of Georgia Families Supported Decreased 21% (2004-06)*

*As reported by the Georgia Department of Human Resources

Source: Braddock et al. (2007, preliminary)

86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06

Fiscal Year

0

2,000

4,000

6,000

8,000

10,000

Number of Participants

499

1,056

545

2,0172,669

7,9087,598

5,648

8,2428,585

6,801

Network Response to Decreased Support

Demonstration and Funding ProposalsProvided within MRWP waiver as “Natural Supports”Some state funded

Family Support 360 grant 24 established Navigator Teams With the support of Children’s Trust Fund dollars and

Parent Leadership Coalition Support 30 more Navigator Teams will be established in the next year

Challenges in DD ServicesOlmsted in GeorgiaMedicaid: EPSDT, Katie Beckett, and

WaiversProvider CapacityFamily SupportEducationTransitionEmploymentAging

IDEA: Children Served• Child Counts (2004)

• Age 3 -5: 20,801• Age 6- 21: 175,127

• Highest incidence 1. SLD

2. SLI

3. MR/DD

4. ED

5. OHI

IDEA• State’s performance goal for 3 years

• Include 90% of the children with special needs in the regular classroom at least 80% of the day

• Effort has resulted in significant improvement in the state’s CRCT test scores: SWD made gains in every subject in every grade

Current Issues in Education• Senate Bill 10• Revision of diploma regulations• Special education funding formula revision

Challenges in DD ServicesOlmsted in GeorgiaMedicaid: EPSDT, Katie Beckett, and WaiversProvider CapacityFamily SupportEducationTransitionEmploymentAging

Transition

• Each year about 700 students with developmental disabilities exit the school system and go on the waiting list for adult services

• Challenges include making multiple systems work together for employment and real community activities

Network Response to Transition Issues

• Statewide Transition Steering Committee • Convened by the DD Council and DOE• Meets regularly to review best practices , disseminate

information, and recommend policy to the State Advisory Panel and the State Board of Education

• Working on diploma options, special education funding formula, and successful models for employment

• Supports Partnership for Success Inclusive High School Grant

• Will advise Transition Component of Employment First Georgia Institute

Challenges in DD ServicesOlmsted in GeorgiaMedicaid: EPSDT, Katie Beckett, and WaiversProvider CapacityFamily SupportEducationTransitionEmploymentAging

Employment• 19.7% of adults with developmental disabilities in

supported employment• By end of 2007 the goal is 25%

• 80% of employment was sheltered employment, facility-based work models and non-work models (2004)• Only 20% was integrated employment

Georgia has to make a switch from facility non-work day services to integrated, community-based employment

Network Response to Employment Issues

• Provide opportunities for employers and consumers to see innovative employment in action

• Sponsors Discovery Day which • Allows corporate Atlanta opportunity to explore

employment opportunities for people with disabilities• Provides opportunity for employers, providers, and

people with disabilities to meet, exchange ideas and network

• Established and partially funded Employment First Institute

Challenges in DD ServicesOlmsted in GeorgiaMedicaid: EPSDT, Katie Beckett, and WaiversProvider CapacityFamily SupportEducationTransitionEmploymentAging

Aging: People with DD are Healthier and Living Longer

• 17,000 Georgians are living with caregivers over 60 years old• Respite is greatest unmet need of older families caring

for adults with disabilities

• 35% are living with middle-aged caregivers• Long waiting lists for community services, even those

on the short term list

Network Response to Aging Challenge

• Support Aging and Disability Resource Connection (ADRC)• Located in Atlanta and Augusta• Handled 45,000 contacts for resource and

referral network• State legislature funded three additional sites

• Coastal Georgia AAA and MHDDAD Region 5• Northeast Georgia AAA and MHDDAD Region 2• Southern Crescent AAA and MHDDAD Region 1

• Support Naturally Occurring Retirement Communities

Georgia is Improving!

Georgia’s national ranking has moved from 44th to 30th with regard to community based services!

State TreasuresOlmstead state

Sue JamiesonElaine WilsonLois Curtis

Connie and John O’BrienCitizen AdvocacyCollaboration within the DD network

Major Collaborative ProjectsChildren's Freedom InitiativeUnlock the Waiting List CampaignSelf AdvocacyEmployment First Georgia