ODDC- Ohio Access for People with Disabilities

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Title: Ohio Access for People with Disabilities

Author: Office of Budget and Management, http://www.obm.ohio.gov/media/reports/ohioaccessrpt.PDF (KACW 11/3/03)

The FY 2002-2003 Executive Budget: In June 2000, Governor Taft, continuing his commitment to provide community-based alternatives for elders and persons with disabilities, proposed approximately $145 million over the biennium for new initiatives and expansion of existing programs for Ohioans with disabilities. Under current law, spending for direct care, like labor costs, is projected to increase 9.2% in FY 2002 and 9.3% in FY 2003. The Executive Budget preserves this increase. These recommendations include:

Improve access to information regarding services
Expand Current Home & Community Based Waiver Programs- Across all delivery systems, the number waiver slots approved by HCFA increased from 11,064 in FY 1992 to nearly 38,000 in FY 2000. This represents a 242% increase over FY 1992 levels. Governor Taft is committed to the continued expansion of community-based alternatives.
Create New Opportunities for Independent Living- The Ohio Access Success pilot (‘seed money ‘for the first month’s rent, utility deposits, etc) would fund up to $2,000 for 75 individuals in FY 2002 and 125 individuals in FY 2003.
Develop cost management tools that promote choice and personal responsibility
Redesign the MR/DD Medicaid Delivery System-In response to concerns of consumers’ families, county boards, and HCFA of the need to redesign the delivery system to expand residential capacity, increase consumer choice, and improve management accountability, Ohio began a redesign effort.
Improve cost management tools within the community mental health system.
Remove fiscal incentives that subsidize excess nursing home capacity.
Protect the current reimbursement formula for patient care.

Department of Job and Family Services: The Ohio Medicaid program provides services such as inpatient hospital, outpatient hospital, prescription drugs and durable medical equipment. In Ohio, optional covered services include private duty nursing, physical therapy, occupational therapy, speech and hearing, and community behavioral health care service. Ohio covers waiver services such as home-delivered meals; supplementary equipment/adaptive devices, home modification, out-of-home respite, adult day care, supported employment, and homemaker/personal care services.

As of July 1, 1996 the Ohio Department of Human Services revised its home health services providing home care services to Medicaid eligible consumers. ODJFS is charged with assuring the health and safety of the consumers enrolled in the Home Care waiver. The Ohio Home Care Program describes the following benefit packages:

Core Benefit Package (administered by ODJFS)
Core Plus Benefit Package (administered by ODJFS)
Home Care waiver (administered by ODJFS)
PASSPORT waiver (administered by the Department of Aging)
Individual Options (IO) waiver (administered by the ODMR/DD)
Residential Facilities (RFW) waiver (also administered by ODMR/DD)

As of February 21, 2001, 7,343 consumers in were currently or had been enrolled on the Ohio Home Care Waiver and there were a total of 2,366 individuals on the OHC waiting list. OHC Waiver’s is targeted toward people age 60 who would require nursing facility level services or long-term hospital care without the service. Approximately 30% of enrollees were under 18 years of age and 62% were diagnosed with ‘Diseases of the Nervous System and Sense Organs’. The OHC Waiver provides daily living assistance, skilled nursing, home delivered meals, adaptive devices, home modification, out-of-home respite, adult day care, and transportation. Costs vary up to as much as $14,700 per month.

The Ticket to Work and Work Incentives Improvement Act enabling people to work without losing their Medicaid coverage, also allows states to:

Cover groups of persons with disabilities not previously covered
Apply for grant funds for outreach or infrastructure development
Impose premiums or cost-sharing charges on a sliding scale based on income

Department of Mental Health: The majority of people who received mental health services in FY 1998 required only brief intermittent treatment. A subset of this population, severely mentally disabled (SMD) adults and severely emotionally disturbed (SED) children, account for the majority of service utilization and expenditures. While 74,348 Severely Mentally Disabled (SMD) adults and Severely Emotionally Disturbed (SED) children served in FY 1998 represent only 30% of people served in the system, they required $470 million, 60% of the community expenditures. Preliminary reviews of the approximate 11,600 adults with the most severe and persistent forms of mental illness found that more than 100 mentally disabled adults staying in hospitals, and approximately 300 staying in adult care facilities for a long period of time could better be served in community settings.

Department of Mental Retardation & Developmental Disabilities (OMR/DD): In 1989, the "developmental disability" definition was changed and based on limits on "major life functions." This definition included other disabilities, such as cerebral palsy and epilepsy, but excluded many people with mild mental retardation making them ineligible for services, unless they were already receiving services when the definition was changed. Both people living in institutions and those receiving Medicaid waiver services must have an ICF/MR "level of care" indicating that the person requires institutional services or comparable community services.

The MR/DD system provides various services, including early intervention, education, family support, therapies, employment services, and residential options. Medicaid home and community based waiver services (HCBS) have grown dramatically during the 1990s from $2.3 million in FY 1992 to $170 million in FY 1999. A large share of that growth came from adding the Residential Facility Waiver (RFW) in FY 1998.The cost of waiver services must, on average, be lower than the cost of ICF/MR services.

In 1967, County Boards of MR/DD were created to plan and monitor community services. As of October 1999, they were serving 54,400 Ohioans with MR/DD and received $546 million in local taxes. This amount offsets half the cost of community residential services the boards provide and represents a significant increase from the $292 million raised by local levies in 1990. The majority of ICF/MR services, many supported employment and specialized therapy services are also provided by private organizations through contractual arrangements with county MR/DD boards. Both county boards of MR/DD and private providers are regulated by ODMR/DD, a cabinet-level department since 1980.

The Individual Options home and community based services waiver, established in 1991, enabled more people to live in their own homes, with paid support. Developmental center populations continued to decline, from 2,359 in FY 1992 to 2,004 in FY 1998, while waiver-funded support for people living in the community grew from 420 people in FY 1992 to 4,093 people in FY 1998. An additional 1,541 people were living in group homes with state funding. In 1999 after conducting a review, HCFA found several problems with the RFW system. OMR/DD and ODJFS, with participation of other key stakeholders, are currently addressing those problems, in preparation for extension of the RFW and expansion of waiver capacity.

The 1989 Martin case, challenging the use of waiting lists, is still in process. There are over 4,500 people with MR/DD living at home with aging caregivers in Ohio. There are over 6,500 people currently on waiting lists. ODMR/DD is reassessing all personnel and service costs in Developmental Centers to ensure that these services are delivered cost effectively without compromising quality.

Department of Aging: While the Department of Aging’s programs include many diverse activities, principal funding for home and community-based services come from four different funding streams:

Medicaid (through PASSPORT) providing personal care for people over 60 in their home preventing them from going to nursing homes
The Older Americans Act providing services like home-delivered meals and home repairs to 19,200 people. The funding has been static creating a waiting list for some services.
Residential State Supplement program providing an income subsidy to very low income persons age 18 and older to allow those individuals to reside in less restrictive settings than a nursing facility. The General Assembly has capped the number of RSS participants at 2,800 at any given time and the program has reached this level. New participants may be added when an existing participant leaves the RSS program, resulting in a "waiting list" for RSS of approximately 1,000 individuals statewide. Currently, all RSS clients are under age 60 and 70% indicate a chronic mental illness.
State GRF funding through the Senior Community Services Block Grant

Department of Health: The Bureau for Children with Medical Handicaps (BCMH) provides health care and coordination services to eligible children with special health care needs (CSHCN) and their families. During FY 1999, the Bureau served 32,534 children, families and adults through its diagnostic, treatment and service coordination efforts at a total cost of $21 million. Team service coordinators and public health nurses located in local health departments assist families in finding resources allowing children to remain in their homes. The Family Stability Fund of the Family and Children First Council prevents out of home placement of children by:

Assessing the child’s and family’s needs
Developing a plan, including a crisis plan
Assuring that the family has the needed resources and supports to follow through with the plan
Monitoring the child’s and family’s response to interventions in the plan, modifying the plan as necessary
Communicating with others involved in serving the child and family to assure understanding and completion of common goals.

Since the 1970s, the ODH has conducted screening of all newborn infants for metabolic diseases. Two of these diseases, hypothyroidism and phenylketonuria (PKU), lead to profound mental retardation if not identified and treated within a few weeks of birth. Sixty-three infants were diagnosed in 1999 with one of these two diseases. Individuals with PKU require a special formula, which is also provided through the ODH. Ohio’s Early Intervention Program has been a national leader in identifying children with developmental delay. The Ohio Department of Health has the responsibility for children aged birth to three years of age. Networks of providers have been formed in every Ohio county to identify affected infants and children, and refer them for assessment and an individualized family treatment plan and follow-up services included in that plan. In FY 1999, 11,454 individuals were served at a cost of $8.92 million.

Department of Alcohol & Drug Addiction Services: The department allocates most federal and state funds through local Alcohol and Drug Addiction Services and Alcohol, Drug Addiction and Mental Health Services (ADAS/ADAMHS) Boards to fund local programs for community-based services. In FY 1998, 95,221 Ohioans received publicly funded alcohol and/or other drug treatment and 15%, were Medicaid eligible. ODADAS’ Medicaid services include the following:

Alcohol and drug screening analysis
Assessment
Case management
Individual and group counseling
Crisis intervention
Intensive outpatient treatment
Ambulatory detoxification
Methadone maintenance

Public Involvement in the Ohio Access: Consumers, their families, providers, and local government partners of OMR/DD gave personal input and ideas to develop changes and/or expansions to existing services. Consumers were positive about the state’s HCBS waiver expansions over the past decade, but they indicated that more resources should be directed to community care alternatives. Other popular topics across all delivery systems were access, consumer choice of caregivers, and various challenges associated with the health care workforce shortage. OMR/DD recruited 17 people to define its mission for the future.

The Director of the Department of Mental Health appointed a time-limited commission to recommend changes in the vision for mental health. The Commission is the second stage in the Department’s Building Our Future Together Initiative, which began with a series of nine public forums throughout the state in the fall of 1999. The Commission’s report, which was published in January 2001, includes new statements of mission, vision, and values for mental health in Ohio, and recommends a strategy focusing on fundamental principles:

Access
Effective treatment
System design, function, and integration
Financial support

The Departments of Job and Family Services and Aging held a series of ten Ohio Access forums. Consumers want to receive services in the setting they prefer, more control over the types of services they receive and the provider who delivers the service, including the ability to hire and fire service workers. Additionally, they said funds should follow consumers from an institution back to the community setting. The lack of housing alternatives and transportation were cited as a barrier for people returning to the community. There was also concern about the delivery capacity of the current system creating long waiting lists. Finally, the worker shortage has contributed to a feeling of dissatisfaction with current home care providers who can no longer promise to be an effective backup when workers call off or simply fail to show up.

Federal Constraints: Since Medicaid is a joint federal/state partnership; each state establishes its own eligibility standards, benefits package, payment rates, and program administration under federal guidelines. These federal guidelines control such important aspects of state Medicaid policy as who is eligible, what services they receive, and who can provide Medicaid-funded services. Federal Medicaid policy has constrained the flexibility in four ways:

The federal Medicaid program has a long-established institutional bias mandating that certain services be covered in state Medicaid programs, while others such as personal care, are optional
Fragmentation in funding and policy exists between various different federal agencies making it very difficult for states to coordinate programs and funding streams
The federal Medicaid program has built-in inflexible requirements, such as the "Freedom of Choice" provision prohibiting states from using market-driven concepts such as competitive bidding and direct negotiation to control service costs and ensure quality
States have been very concerned over the amount of staff time it takes to get a Medicaid waiver.
Federal programs such as Housing and Urban Development (HUD), Medicare, and Rehabilitation Services have provided essential support to persons with disabilities, but they have operative policies working against disabled consumers in community settings.
Most states are facing enormous budgetary pressures to control the growth of Medicaid, currently about 20% of the average state budget

Challenges to State Disability Policy: Not only do state and local policy makers have to equally distribute the limited resources among populations with diverse service needs, but all public funded delivery systems are competing for the same pool of limited state resources. The federal government pays approximately 59% of all direct care and residential service costs for Medicaid-eligible Ohioans in institutional settings but not in the community. Community residential costs are borne by the consumer, a state or local government entity, a nonprofit, or some combination. If a person is eligible for Medicaid long-term care community placement, the state pays approximately 41% of the costs of the individual’s direct Medicaid services. The remainder is shared with, or borne solely by, a county board entity. County boards use substantial funds, from both state allocations and local levies, to provide the state share of Medicaid match. Failure of local levies or changes in board priorities could create serious equity issues that could be solved with additional state funding or by reducing the number of waiver slots to fit the funding available.

The solution to the health care labor shortage must include a component that allows for a sufficient number of workers to be sustainable for a variety of settings including nursing homes, adult foster care and assisted living. Individual consumers wishing to hire their own workers and self-direct their care are also competing for the same types of workers. This number has remained relatively stable in recent years; however, the increased demand for community care options is increasing. It is expected to not only continue, but worsen, largely due to a number of demographic influences. The U.S. Census Bureau has estimated that the rate of growth of persons aged 65 and older has far exceeded the growth rate of the population as a whole and will more than double by the year 2030 from 33 million in 1994 to 80 million. The group 65 and older is growing at an even faster rate.

RECOMMENDATIONS: Ohio Access’ underlining principle is that government programs should respect and integrate with the family’s historic and primary role in care giving. The cornerstone of the Ohio Access vision is consumer self-determination and a person centered planning approach with assistance from family, friends and caregivers. While Ohio has dramatically increased its spending on community services for persons with disabilities over the last decade, the funding imbalance has been so great that 75% of the funding for Medicaid long-term care, services, and supports is still used for institutional care. The statewide vacancy rate in nursing facilities is approximately 13% at a time when a significant waiting list exists for Ohio’s home and community-based waiver. Increased spending on home and community-based services will allow state agencies to serve an additional 5,000 consumers during the next biennium. Beyond the proposed budget, the state should:

Realign its public resources in response to consumer demand
Provide better information and assistance for consumers and their caregivers
Work with institutional providers to examine new ways to transition to new models in the community
Implement a small transition pilot program allowing those in nursing homes to transition to the community
Implement self-determination strategies in the twelve developmental centers
Obtain a waiver of Medicaid requirements to establish a range of cost and quality controls permitting state systems to manage a program of Medicaid funded services.
Study ways to better link all programs that provide community services to persons with disabilities
Clarify the role, responsibilities, and strengthen accountability for local and regional entities responsible for assisting consumers and their families in accessing and coordinating services.
Increase the participation of consumers and family members in assessing the quality and effectiveness of services.
Develop and test new strategies that enable health care and related professions to compete with other expanding job opportunities by:

Examine "scope of practice" issues; including delegated nursing and responsible alternatives to delegated nursing.
Explore the use of available technology, which can allow individuals to stay home and decrease the need for human help to reduce reliance on an overburdened labor force.

State agencies responsible for providing publicly funded long-term care, supports, and services made the following recommendations:

Continue to comply with ADA, allowing consumers to choose the most integrated settings for services
Seek federal approval for additional state flexibility in adopting market-based and value purchasing-driven strategies for working with service providers,
Seek additional federal flexibility in the type of community services and work with the new federal administration to better address the housing needs of low-income persons with disabilities.
Explore options that create opportunities for people with disabilities to work while still receiving health care coverage, especially the federally created "ticket to work" initiative.
Examine successful programs, such as the LEAP program in Cleveland that trains persons with disabilities to become care workers themselves.
Develop a public policy by which those with resources may contribute some portion toward funding needed community services without jeopardizing their eligibility for those services.
Encourage Ohioans to plan for their future needs for long-term care, services, and supports.

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