- TITLE:Delivering on the Promise: Department of Health and Human Services Self-Evaluation to Promote Community Living for People with Disabilities-Chapter 3 Action to Address the Barriers
- AUTHOR: Specific author unknown (KACW 4/8/03)
- MEDICAID- ELIMINATING INSTITUTIONAL BIAS: The Centers for Medicare and Medicaid Services (CMS) are attempting to eliminate the bias for institutions in the Medicaid program by: improving waiver stability by requiring Home and Community Based Services (HCBS) waivers to be renewed every three to five years; clarifying temporary expenses in the community, such as security deposits or furniture, are feasible under the HCBS; allowing states to tighten the eligibility requirements for hospital and ICFR/MR admissions, permitting states to set HCBS waiver eligibility at any hospital or ICF/MR level of care; and allowing states to narrow their application of income or resources in determining Medicaid eligibility for people living in the community. HHS will develop and implement strategies to improve access to HCBS waiver and non-waiver services for adults and children with mental illness or emotional disturbances, or co-occurring mental illness and substance abuse or other disorders by issuing technical assistance and guidance to improve state understanding of existing options.
Services for Children in Residential Treatment: CMS will propose statutory improvements to create an evaluated, 10-year HCBS demonstration as an alternative to Medicaid-funded psychiatric residential treatment centers. The demonstration would allow states to set up home and community-based alternatives for children who would typically be served in psychiatric residential treatment facilities. Extending HBCS waivers as an alternative to residential treatment facilities would allow children treatment in their homes at a cost per child which is less than institution care.
- MEDICARE: ELIMINATE OR REDUCE INSTITUTIONAL BIAS:
Durable Medical Equipment: CMS will examine methods to improve access to durable medical equipment (DME), including revisiting the operative definition of DME in light of the Ticket to Work statute to determine if it should include additional technologies to promote independence and community living. Allowing people leaving skilled nursing facilities to be furnished with equipment a month before their transition; and requiring a trail rental period for expensive medical equipment will be considered.
Direct Service Workers: HHS will initiate, together volunteer states, a national demonstration designed to address workforce shortages of direct care workers. The demonstration will test the extent to which workforce shortages and instabilities might be addressed through better coordination with the Temporary Assistance for Needy Families (TANF) program and the availability of vouchers for worker health insurance, tuition or day care credits. Participating states would be expected to develop options for workers to purchase affordable group health coverage through the state health insurance system or similar organized insurance group. CMS and the Office of the Assistant Secretary for Planning and Evaluation (ASPE) will collaborate on an initiative to mobilize and make available to states a coherent body of information about methods to address worker shortage issues, research significant issues, and partner with foundations, other private sector organizations, the Department of Labor, and other agencies to formulate a comprehensive approach to the worker shortage issue.
Medicaid Buy-In Improvements: HHS will seek improvements to federal legislation that would permit states to: establish a minimum threshold for work, up to 40 hours per month, in order for individuals to be eligible for participation in the state Medicaid buy-in programs; remove the age limitation clause in the Ticket to Work legislation that eliminates Medicaid buy-in options when a worker with a disability is age 65 or older; and use disability determination criteria in the Medicaid buy-in program that exclude employment status.
- PROMOTING INDEPENDENCE, RESPONSIBILITY, AND CONSUMER-DRIVEN SERVICES:
Person-Centered Planning: CMS will update its regulations regarding Medicaid case management to emphasize person-centered approaches pioneered by states.
Self-Directed Services Waiver: CMS will provide states a simplified model waiver on electronic media that offer both person-centered planning and self-directed service options. CMS will also develop technical assistance materials outlining existing options for states to develop flexible, cost-effective and consumer-driven methods of providing home health or personal assistance services.
Health and Disability Education and Mentoring: The Centers for Disease Control and Prevention, with the Department of Education and others, will continue its educational and self-help curriculum, pioneered with the nation's Independent Living Centers, entitled "Living Well with a Disability."
- ASSISTANCE TO FAMILIES AND INFORMAL CAREGIVERS:
Model Waiver and Demonstration for Family and Caregiver Support: CMS will develop a model simplified, streamlined, electronic waiver application form designed to permit states to offer a flexible array of supports for caregivers and the individuals for whom they provide assistance.
Medicaid Respite Services for Adults: HHS will seek authorization and funding from Congress to conduct a ten-year national demonstration allowing states to provide respite care for adults as a fixed budget demonstration. The state option would provide relief to unpaid caregivers within specified federal limits. CMS will also seek authorization and funding from Congress to implement an evaluated, 10-year demonstration to provide relief to caregivers of children who have a substantial disability.
- COORDINATION AND REDUCTION OF FRAGMENTATION:
HHS Office on Disability and Community Integration: HHS will establish an Office on Disability and Community Integration to oversee the coordinated development and implementation of policies, programs and special initiatives within HHS that impact people with disabilities regardless of age or type of disability.
Disability Advisory Committee: HHS will establish a Disability Advisory Committee, consisting of individuals with disabilities, family members of individuals with disabilities, advocacy organizations, providers and state and local government representatives, to review and advise HHS on the implementation of solutions set out in this report, and will provide information and advice to the HHS Office on Disability and Community Integration on community integration issues.
Interagency Council on Community Living (ICCL): HHS proposes that the President formalize permanently the Interagency Council on Community Living (ICCL), to accomplish the tasks set out in Executive Order 13217.
- ACCOUNTABILITY AND FULFILLMENT OF LEGAL OBLIGATIONS:
Complaint Resolution and Voluntary Compliance: Office of Civil Rights (OCR) and the Department of Justice (DOJ) will develop a pilot program to use DOJ's alternative dispute resolution (ADR) program for the resolution of appropriate complaints filed with OCR alleging that individuals with disabilities are not being provided services in the "most integrated setting appropriate to their needs," under ADA Title II regulations as interpreted in the Olmstead decision. Since 1994, DOJ has maintained an ADR program where professional mediators who have been trained about ADA legal requirements help adverse parties devise mutually acceptable solutions in appropriate cases involving alleged violation of the ADA.
Broad Dissemination of Information about Voluntary Compliance: HHS will expand its distribution of information to states, tribes, and other stakeholders of information about: voluntary compliance with the ADA's most integrated setting regulation and the Olmstead decision; promising practices in the providing services in the most integrated setting; and examples of people who have moved from institutional to community life.
Clarification of Medicaid Policies Affecting Individuals with Psychiatric and Co-Occurring Disorders: CMS will clarify existing Medicaid policies identified as confusing or prone to misunderstanding relating to community-based services for persons with psychiatric and substance abuse disabilities and children with serious emotional disturbances, and will provide necessary technical assistance on these policies to states to assist them to make full use of existing Medicaid programs.
Increased Regional Efforts to Provide States with Technical Assistance to Promote Olmstead Compliance: HHS will create intradepartmental workgroups in each HHS region to work with states to promote compliance with the ADA and the Olmstead decision. These groups will bring together key federal components, including CMS, OCR, AoA, SAMHSA, HRSA, ACF, HIS and others to provide hands-on technical assistance across programs on how to provide expanded, better, more effective and appropriate community services for individuals with disabilities. The regional teams will work with states to identify potential sources of funding and to implement best practices.
Technical Assistance on Services for Older Persons: The Administration on Aging (AoA) will provide more technical assistance and guidance to states regarding the options available to them to creatively shape their services to best meet the needs of their elderly populations.
Develop a Multi-Pronged Strategy to Address Quality of Care Issues in Home and Community-Based Services: HHS will address quality of care issues in home and community-based services through a multi-pronged strategy developed in consultation with states and individuals with disabilities or long-term illnesses. This strategy will include: establishing defined expectations for waiver and non-waiver home and community based services; assisting states to design better systems of quality assurance and improvement that increase the state’s response capability and prevent future problems; and providing technical assistance to states and CMS regions in effective systems design or quality improvement strategies.
Quality Improvement: Through an independent national contractor, CMS will assess the current state of the art in community-based quality systems and assist states in the following: using the results of CMS quality reviews; taking prompt remedial action for identified problems in HCBS programs; designing better systems of quality assurance and quality improvement that increase the state’s response capability and prevent future problems; and ensuring effective system design or quality improvement strategies.
Action Reinvestment for Quality: CMS will develop improvements to HCBS waiver administration for legislative or regulatory consideration that will increase the prospect for prompt and effective remedy of identified problems.
Applied Knowledge: CMS will work with states, universities, foundations and others to ensure that there is an adequate base of applied research and knowledge to inform public policy-makers with regard to: the impact of the Medicaid and Medicare actions under the President’s Executive Order; state initiatives to improve community living services, methods for designing long-term care systems so that they promote the ADA and are capable of addressing expected population growth due to demographic changes, and methods for designing quality assurance and improvement systems uniquely suited for services in one’s own home.
Adequate Management Infrastructure: CMS will develop an initiative to improve the ability and infrastructure at state and federal levels to account for HCBS and institutional expenditures, analyze trends, identify potential for improvement, implement quality improvement processes, and promote community living through improved management capability and research.
Systems Change Grants: CMS will offer "phase II" of its "Systems Change Grant Program" to assist states in developing services and infrastructure necessary to enable people of any age or disability to live and participate in their communities.
Disability Policy Fellows Program: HHS will establish a program to recruit the expertise of talented individuals who have direct personal experience with a major disability to work in HHS agencies for 1-2 year assignments on a full- or part-time basis, under the Intergovernmental Personnel Act (IPA). HHS will also establish a companion initiative to permit key HHS components that administer disability programs to hire, in permanent positions, a limited number of highly capable individuals with a disability. These personnel programs will be undertaken consistent with the federal government’s responsibilities under Section 501 of the Rehabilitation Act, Executive Order 13163 and the department’s Plan for Employment of People with Disabilities in the federal government.
- MORE INFORMATION: This report contains three appendices. The first summarizes existing research and discusses the barriers identified by HHS components and the various stakeholders who provided input during the HHS self-evaluation process. The second one is a list of acronyms. The third one discusses the components of HHS.
