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President Bush's A.D.A. Anniversary Speech
THE OLMSTEAD INITIATIVE
Community Integration Oversight Advisory Committee
Draft Community Integration Priorities for 2005
Executive Order 84 Recommendations from the Olmstead Initiative Implementation Team
Draft Community Integration Priorities for 2005
Please Note: The Committee has adopted five (5) top community integration priorities and is considering presenting these five and nine (9) additional recommendations in its October 2005 report to Governor Warner. The 14 recommendations are those that we believe are most essential to support adequate and appropriate infrastructure of community-based services, and are needed either to move people from institutions to the community or to prevent unnecessary or unwanted institutionalization.
The 14 recommendations appear below, organized within three major categories: Community Infrastructure, Increased access to services and supports by those currently eligible for them, and Increased access to services and supports by those not currently eligible for them. The Committee's top five priorities are indicated immediately preceding the recommendations to which they apply.
Thank you very much for your comments.
I. Community Infrastructure
A. Priority #1: Increase all Medicaid reimbursement rates to include the maximum allowable cost of service; automatic cost of living adjustments (COLA); geographical rate differentials; travel and transportation; staff training and supervision; and inflation.
- Ensure that caregiver pay rates are reflected.
- Reimburse Direct Support Professionals (DSPs) at higher pay and benefits for certifications and career enhancement.
- Increase Medicaid reimbursement rates for transportation services to adequately cover the cost of operations.
B. Priority #3: Continue to fund and develop community services to eliminate the State mental health facility discharge waiting lists.
C. Priority #4: Develop and fully fund incentives to attract and retain qualified candidates to disability fields of care:
- Develop a larger skilled professional staff pool by aggressive recruitment and training efforts.
- Increase the available pool of providers by re-titling Direct Care workers, paraprofessionals, and others to "Direct Support Professionals." Ensure that regulations and training materials use that title.
- Provide information and documents to DSP employers to help them make DSPs aware of, and help them apply for, State and Federal programs and benefits for which they may be eligible.
D. Develop funding, fiscal and other incentives for providing and establishing new services, including employment and quality integrated community-based day support Medicaid-funded services.
E. Include employment as an issue in discharge planning protocols for individuals wishing to work in the community.
F. Promote recovery-oriented services designed to prevent institutionalization for adults with serious mental illness, including effective consumer-operated and peer services. Develop a mental health consumer group to mentor those seeking transitions.
II. Increased access to services and supports by those who are currently eligible for them
A. Priority #2: Increase the availability of funded Medicaid Waiver slots. Continue to eliminate waiting lists for Waivers and other supportive services; avoid future waiting lists by anticipating regular increases in need for services. Fund 25% of 2003 waiting list in 2005; 45% of 2004 waiting list in 2006; 65% of 2005 waiting list in 2007; 80% of 2006 waiting list in 2008; and 100% of waiting list, except those waiting 90 days or less, in 2009. Require DMAS to include on the urgent waiting list people in nursing facilities and Intermediate Care Facilities for the Mentally Retarded (ICFs/MR) who are ready for discharge and who want to move. The number of slots to be allocated as "institutional" slots would be determined according to the following formula:
- Add the number of people in nursing facilities and ICFs/MR who are discharge ready, and who want to move, to the number of people on the Urgent list, making sure they are not counted twice.
- When new slots are allocated, base the percentage of slots allocated to people in institutions on the percentage of people who meet the above criteria, when compared to the total percentage of people on the Urgent list.
For example, if people in institutions constitute 10% of the total list, then 10% of any new slots would be allocated for people in institutions.
B. Increase the personal maintenance allowance (PMA) to 300% of the monthly SSI payment limit in all Waivers. Currently, the state allows an individual to retain $579 to pay rent, utilities, food, clothing, and other expenses. The Joint Commission on Healthcare has twice recommended that the PMA be increased to a more realistic level.
C. Establish and grant emergency regulatory authority for a revolving fund for people in institutions to use for utility and rent deposits and other upfront household expenses to enable them to move from institutions.
D. Amend Va. Code § 54.1-3000 and other relevant sections (commonly known as the "Nurse Practices Act") and associated regulations to exclude personal assistants, respite workers and companion aides under direction of a consumer or his/her surrogate from the requirements of the Act. Model the amendment on provisions in the Kansas statute that permit attendants to provide activities if the activities may be performed by the individual if the individual were physically capable, and the procedure may be safely performed in the home.
III. Access to services and supports by those who are not currently eligible for them:
A. Priority #5: Increase Medicaid financial eligibility to 100% of federal poverty level.
B. Fund the Brain Injury Waiver.
C. Implement the Dementia Waiver.
D. Assure that State level consolidated and housing agency plans identify persons with disabilities as a high priority housing need population. Mandate agencies, in allocating Section 8 voucher assistance, grant funds and low- and no-interest loans and technical assistance to assign high priority to these needs.
Executive Order 84 Recommendations as Presented by the Olmstead Initiative Implementation Team
Please Note: Executive Order 84 directed that the state agency Implementation Team make six specific recommendations to the Committee, and that the Committee make six specific recommendations to the Governor. The Second Annual Implementation Team Report, issued July 15, 2005, contained the Team's recommendations, which appear in their entirety below. The Committee is now considering these recommendations and will formulate its own recommendations for inclusion in the Committee's October report.
Thank you very much for your comments.
Increasing membership of people with disabilities, family members, and surrogate decision-makers on state and local boards and commissions
Relevant state agencies could contribute to the preparation of a comprehensive packet of information that would be distributed to all state and local government entities in the Commonwealth to assure the availability of consistent resource materials. The packet could be assembled and distributed by the Office of Community Integration for People with Disabilities (OCI) and include information about:
- The ADA [Americans with Disabilities Act];
- The Olmstead Initiative;
- Why it is important to involve people with disabilities;
- What has already been done to increase participation;
- How to locate and use meeting accessibility and accommodations guidance documents;
- How to locate and recruit qualified people with disabilities;
- Website addresses with further resources; and
- Disability etiquette.
People with disabilities need to be aware of programs and resources available to assist them in preparing to serve.
- Disability Services Boards (DSBs), CILs [Centers for Independent Living], CSBs [Community Services Boards], and other consumer advocacy groups could serve as a resource for ongoing information for people with disabilities who would like to serve on work groups, task forces, boards and commissions;
- Programs such as DMHMRSAS' CELT [the Department of Mental Health, Mental Retardation and Substance Abuse Services' Consumer Empowerment and Leadership Training] could be more widely advertised and expanded, as appropriate, and VBPD's [the Virginia Board for People with Disabilities'] Partners in Policy-Making could be more widely advertised so that more people would be aware of the opportunities these programs offer; and
- Agencies could earmark a modest amount of funding for travel reimbursement and related expenses that would otherwise deter or prevent a person with a disability from participating as a member of work groups, task forces, boards and commissions.
At the state level, ADA Coordinators or other designated persons within all state agencies could be responsible for:
- Maintaining lists of agency work groups, agency task forces, and gubernatorial boards and commissions related to that agency;
- Actively seeking out and maintaining a list of people with disabilities interested in serving on these work groups, agency task forces, and gubernatorial boards and commissions;
- Helping to match people with disabilities to other agencies' work groups and task forces;
- Consulting with disability services agencies when they lack names of qualified candidates; and
- Providing a link on each agency's website and/or intranet to the accessibility considerations and meeting planner guidelines currently on the Olmstead website.
ADA Coordinators or other designated persons at state agencies responsible for providing services to people with disabilities could assist other state and local agencies that may be less familiar with these issues in the following areas:
- Naming and training an ADA coordinator;
- For small agencies not required to have an ADA Coordinator, how to accomplish the same goals; and
- Making local agency ADA Coordinators aware of both their responsibilities and the resources available to them on an ongoing basis.
2. Establishing and maintaining a list of residents, by disability, who are appropriate for discharge, who want to be discharged, from nursing facilities and assisted living facilities
Nursing Facilities:
As discussed [elsewhere in] this report, VBPD recently awarded a grant to VACIL [the Virginia Association of Centers for Independent Living] to inform people with disabilities who reside in nursing homes about community living options and supports, identify individuals who may be interested in moving into more integrated settings, and as feasible, assisting a limited number of individuals to transition to a more integrated setting. VACIL will work with state and other agencies already involved in nursing home transition issues. This grant will serve to begin identifying people who wish to leave nursing facilities over the next 18 months as a bridge to the following.
DMAS [the Department of Medicaid Assistance Services] could work to develop a user agreement with CMS [the Center for Medicare and Medicaid Services] for Minimum Data Set (MDS) data relating to residents' desire to return to the community. DMAS could explore appropriate means of sharing relevant MDS data with the VBPD, so that VBPD could communicate the information to VACIL, and VACIL could use the data to help focus its grant efforts.
Nursing Facilities and Assisted Living Facilities:
- Secure legislation and funding to:
- Mandate visits with nursing and ALF [Assisted Living Facility] residents within 3 months of admission and every year thereafter to explore options for community living;
- Give, and expand the availability of, options to those who currently live in nursing and ALFs; and
- Implement a Statewide case management system;
- Begin to develop a waiting list based on face-to-face contacts with people who show an interest in living in the community. Because DMHMRSAS has managed a waiting list for MH [mental health] facility residents for several years, experts from that Department would be consulted in the development and monitoring of the waiting list; and
- Review existing assessment instruments, procedures and training to encourage consideration of the most integrated settings and policies to incorporate choice.
As a supplement to the above activities, a 1-800 number could be developed for people who would like to leave ALFs or nursing facilities to live in a more integrated setting and information on how to access information in community living options could be posted in all nursing facilities and ALFs similar to the currently required Ombudsman information. The OCI could coordinate this service.
3. Assuring an appropriate statewide system for reporting of allegations of abuse, neglect, serious injuries and deaths by providers of community services and supports to people with disabilities
A statewide system could be developed. All current agency-based reporting requirements could first be identified and assessed. The assessment would include what must be reported in each case (abuse, neglect, injury, death, etc.), and to whom and by whom the report must be made. Compliance with current reporting requirements could also be assessed. Reporting gaps could then be identified, including providers not currently required to report; discrepancies in what must be reported to whom and at what level; non-compliances with current reporting requirements; and disability populations, if any, not currently covered by an appropriate reporting mechanism. Reporting gaps could be addressed through appropriate legislation, regulations, and/or administrative actions. Serious injury and death reports could be maintained by the agency having responsibility for receiving them.
4. Developing a statewide system of consistent rights notification that includes a means by which the quality of information given to [people with disabilities], and the consistency with which information is given, are tracked
The OCI, with the cooperation of all agencies represented on the Team and the advice and consultation of the Committee, could develop one consistent communication regarding community integration, such as that provided by the Office of the Attorney General and currently on the Olmstead website. Such a communication would serve as the basis for a document to inform people of the Olmstead decision, the state's role in community integration and the choices available to individuals with disabilities. The communication could be widely distributed in appropriate ways to individuals with disabilities, family members and surrogate decision-makers, and would be given to nursing facility and ALF residents within three (3) months of admission and annually thereafter in conjunction with the recommendation in number 2 above.
5. Monitoring the quality and coordination of services provided to persons with disabilities, including a process by which complaints relating to the denial, quality and coordination of services provided to persons with disabilities may be made by or on behalf of individuals with disabilities and resolved
Some states, for example West Virginia, have an Olmstead complaint process in place. Continuing research into what other states have done in this area, and specifically how existing complaint processes are being used to further community integration and increase coordination among agencies, would be helpful. Based on results of this research, the Commonwealth may wish to establish a process, possibly within the OCI, whereby individuals could file complaints related to community integration issues.
The Team believes the following to be necessary components of such a complaint process:
- Complaints would be limited to those relating to the desire of individuals with a disability to move to, live in, or stay in the most integrated setting appropriate to their needs, and:
- Unsuccessfully resolved under existing agency processes; or
- Not falling under the jurisdiction of any one particular agency.
- The complaint process would not replace or change any existing agency complaint processes. All existing agency complaint processes would remain intact and, if available, would have to be exhausted before a complaint could be filed.
- The office handling the complaints would have the authority to determine on a case-by-case basis whether or not a particular complaint is appropriate for consideration.
- There would be no authority to overturn any agency decision. The purpose of the process would be to assist the complainant and agency or agencies to reach a satisfactory resolution through mediation.
6. Developing a coordinated reporting system across agencies to monitor the effectiveness of efforts to improve the quality and coordination of services provided to persons with disabilities consistent with the ADA and recommendations in the Task Force Report, including a system to measure and evaluate the performance of the Commonwealth
Working with agencies represented on the Team, the OCI could develop a web-based reporting system for information regarding implementation of Task Force Report recommendations. This database would feature password security, and agencies would be able to log in and enter information related to specific recommendations they are tracking. Examples of information to be submitted would include: any action taken toward implementation of a recommendation, its outcome or predicted outcome, agencies and stakeholders involved in the process, follow-up action/s to be taken, and related costs. The OCI could monitor the data provided by the agencies and analyze it to determine progress toward implementation of Task Force Report recommendations and evaluate the Commonwealth's performance.