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  1. TITLE: Ohio Access Update- Governor Taft’s Strategic Plan to Improve Long-Term Services and Supports for People with Disabilities- February 2004 www.ohioaccess.ohio.gov/pdf/ohioaccessrpt2004.pdf

  2. Author: The Governor’s Cabinet and the Office of Budget and Management (KACW 6/11/04 )

  3. Kathy’s note: This summary assumes that the reader has read the summary of the Ohio Access Report and (11/3/03) and the Update (11//11/03). It also assumes that the reader has a working knowledge of the Olmstead Decision.

  4. Ohio Access: Ohio Access, Ohio’s Olmstead plan, is a comprehensive working plan for improving long-term services and supports for people with disabilities. Governor Taft formalized the Ohio Access planning process in June 2000. The plan directs Ohio agencies that serve persons with disabilities: including Alcohol and Drug Addiction Services, Budget and Management, Health, Job and Family Services, Mental Health and Mental Retardation and Developmental Disabilities. Over the past three years, Ohio Access has served as the primary blueprint for system change. During the past five months, the original 2001 plan was reviewed and modified with input from consumers, providers, and their interested parties. This update sets a clear vision for Ohio where:

    • Ohio’s seniors and people with disabilities live with dignity in settings they prefer;
    • They are able to maximize their employment, self-care, interpersonal relationships, and community participation;
    • Government programs honor and support the role of families and friends who provide care.

  5. Performance Measures The 2004 Ohio Access update includes a number of statewide measures to gauge Ohio’s Olmstead-related progress. The following four statewide measures are tied to the goals of choice, quality, and value.

    • Ratio of people receiving Medicaid home and community based (HCBS) waiver services to people residing in Medicaid-reimbursed nursing facilities and Immediate Care Facilities for the Mentally Retarded (ICFs/MR).
    • Ratio of total public expenditures for community based long-term services and supports to total public expenditures for institutional services.
    • Per member per month (PMPM) rate of growth of total public expenditures for long-term services and supports;
    • Ohio’s ranking on various measures reported by other organizations, such as the American Association of Retired Persons (AARP)

  6. Progress Report: As of June 2003, 42,468 Ohioans were being served with home and community based waivers. This represents a 19 percent increase since the original Ohio Access report was published in February 2001 and a 30 percent increase since Governor Taft took office in January 1999. Since the original report Ohio also achieved the following accomplishments under three guiding principles: increase community capacity, prioritize resources and assure quality and accountability.

    Ohio Department of Aging

    • Passport: 24,891 Ohioans age 60 and over are living in the community, instead of a nursing facility. Passport has grown 10 percent over the past three years and there are no waiting lists. Received a $75,000 grant to study the feasibility of adding adult respite services to Passport.
    • Choices: gives 200 Passport consumers in central Ohio more direct control over service providers.
    • Created a long-term care consumer guide.
    • Coordinates a health care workforce advisory council bringing together consumers, providers, and state agencies to develop strategies to address critical shortages of healthcare workers.

    Ohio Department of Health

    • Took steps to address the healthcare workforce shortage by convening a task force to review health care workforce shortage issues related to licensing standards, scopes of practice, technology to alleviate workload, recruitment and retention, and education.
    • Expanded the Newborn Metabolic Screening Program from 5 to 13 disorders.
    • Help Me Grow: identified 25,645 infants and toddlers eligible for the Help Me Grow program, providing developmental screening and service coordination and ongoing services for infants and toddlers at risk for or with developmental delays and disabilities.

    Ohio Department of Jobs and Families

    • Ohio Home Care and Transitions Waiver programs: served 7,718 Ohioans under age 60 with disabilities or individuals who are medically fragile. Last year, 2,338 people moved to the new Transitions Waiver for people with an ICF/MR level of care, and 41 people moved to existing waiver programs. Home Care now serves 5,380 people with no waiting list.
    • Success Project: A pilot program in the SFY 2002-2003 budget, continuing in the SFY 2004-2005 budget, assist up to 250 nursing home residents in providing one-time costs associated with moving back into a community setting.
    • Received a $50,000 Real Choice Systems Change "Starter" grant to plan for future Real Choice Systems Change activities. These funds were used to involve the Ohio Olmstead Task Force in subsequent grant design and implementation.
    • Received a $1.385 million grant to create a one-stop, on-line resource about services for people with disabilities. ODJFS contracted with ODA to create the site, calling it No Wrong Door Ohio.
    • Received a $500,000 Medicaid Infrastructure grant to explore ways through Medicaid to support individuals who seek to obtain or retain employment.
    • Received a $600,000 Nursing Facility Transitions grant to secure a vendor to design, implement, and evaluate the Ohio Access Success Project.

    Ohio Department of Mental Health

    • Created a statewide network to promote recovery, Centers of Excellence to promote evidence based practices, a consumer outcomes measurement system, and technical assistance to improve cultural competence.
    • Led the nation in deinstitutionalizing behavioral health care services nearly two decades ago and reduced the number of state owned inpatient psychiatric beds by 60% between 1990 and 1998.

    Ohio Department of Mental Retardation and Developmental Disabilities

    • Individual Options and Residential Facilities: 9,843 Ohioans with MR/DD receive services. MR/DD waiver programs have grown 76 percent since 2001, as a result of MR/DD redesign. However, counties still have waiting lists for these programs.
    • Completed a Fundamental Redesign of the MR/DD System: The basic policy changes of redesign, based on consumer self-determination, are complete, but details will continue to be implemented for years. Accomplishments include:
    • Refinanced existing county resources using Medicaid to draw down more than $100 million in new federal funds annually.
    • Developed a new Level I Medicaid waiver program providing opportunities for 6,000 people to live in the community.
    • Provided $14 million in state general revenue funds (GRF) for tax-poor counties to "jump start" Medicaid refinancing.
    • Aligned funds from state ($9.85 million), county ($11 million), and federal ($30 million) sources to increase rates for service providers to recruit and train direct care workers.
    • Supported the recommendations of an Executive Branch Committee that includes representatives of families, county boards, providers, and state agencies to coordinate the redesign effort.
    • Downsized MR/DD Developmental Centers: Over the past three years, the number of residents in developmental centers has decreased 10 percent.
    • Obtained federal approval to expedite the settlement of an outstanding backlog of audits, which will permit settlement payments to Community Alternative Funding System (CAFS) providers in the MR/DD system.
    • Ohio received seven federal grants worth $3.5 million to manage Ohio Access activities.
    • ODMR/DD received a $500,000 Quality Assurance grant to design and implement a quality information management system
    • Implemented an abuser registry to track people who are barred from employment as care providers.

  7. Current Challenges: Although many services for Ohioans with disabilities have been enhanced, there are still several obstacles standing in the way of continued progress.

    8. Limiting Funding: During SFY 2003, funding for primary and secondary education and Ohio’s Medicaid program comprised and will continue to comprise nearly half of Ohio’ s annual spending. Fragmentation in funding and policy exists among federal programs making it difficult to coordinate programs and funding. Receiving CMS’ approval for a Medicaid waiver requires a significant amount of staff time prompting states to call for an increase in flexibility in state plan amendments. Even if budgets are not reduced, inflation affects programs adversely by flat funding. The cost of providing these services is increasing each year, but there is no automatic rate adjustment such as in the nursing home reimbursement formula.

    Federal Policy Constraints: Statutory requirements prevent the state from providing the community-based capacity demanded by seniors and people with disabilities because the first priority for new dollars are the institutional providers. In the mental health delivery system, this was resolved by controlling institutionalization and by permitting resources to follow individuals from institutional settings to community settings. ODMR/DD has instituted a policy allowing the money to follow people who choose to live in the community. During the last two biennial budget development processes, Governor Taft proposed to slow or freeze the growth of reimbursement for nursing facilities and ICF/MR. While CMS has allowed additional waiver flexibility and created grants encouraging states to develop new HCBS alternatives to institutional care, it tightens its interpretations about how Medicaid is to be managed by the states.

    Local Resource Sustainability: Long-term services and supports depend on local resources. Levies provide valuable support for services to individuals who may be quite seriously ill but not Medicaid eligible, and for services Medicaid cannot reimburse. Although some parts of the Medicaid delivery system rely on local levies, recently voters in many board areas have not authorized or expanded levies for these and related purposes. Levy resources are not distributed based on statewide need but on local support. Most Appalachian counties do not have alcohol, drug addiction, and mental health levies although the need for care in these communities is high.

  8. Recommendations: Although the original Ohio Access report focused primarily on fiscal and policy issues, this update focused on other services critical for a person to live with dignity in home and community settings, like housing, employment, transportation, and education. Many of the implementation plans contained in this report are subject to legislative approval via statutory change or the biennial budget process. The next state budget will be introduced in January 2005.

    9. Give consumers meaningful choices: To give consumers meaningful choices, the Ohio Access cabinet will work to: increase home and community based Medicaid waiver programs; provide information about and financially support consumer choice; and support informal caregivers.

    Focus on behavioral health: The Ohio Access cabinet recommends focusing on behavioral health to: maintain public/private inpatient capacity; strengthen behavioral health Medicaid administrative processes; provide access to better care for children; and implement the President’s New Freedom Commission recommendations.

    Improve quality and outcomes for individuals; "Quality" has been redefined to include consumer expectations about autonomy, self-direction, and choice, not just consumer safety. With these new conceptions of quality in mind, the Ohio Access cabinet will: measure service satisfaction and outcomes; address healthcare workforce shortage issues; enhance quality in nursing facilities; and provide training for teachers who work with children with disabilities.

    Get the best possible value from taxpayer investments: The level of reform that is necessary to realign long-term services and supports toward consumer choice and public value can only be accomplished through comprehensive planning. The Ohio Access cabinet will: articulate clear principles for system design; involve consumers in planning and program design; coordinate across agencies; convene an Ohio Access housing task force; implement enhanced care management; and stimulate demand for long-term care insurance.

    Prevent the causes of disability: To improve the state’s effectiveness in helping to prevent the causes of disability, the Ohio Access cabinet will: create a fetal alcohol syndrome prevention initiative; pilot community projects focused on prevention and expand early intervention programs for children.

    Support employment Most people with a disability between the ages of 21 and 64 work (77 percent according to the 2000 Census). However, many people with a disability who want to work are forced to make an economic decision not to because additional income would threaten their health care benefits. The Ohio Access cabinet will: develop a Medicaid Buy-In program; implement Supported Employment in the Mental Health System; and implement the U.S. Department of Labor Employment Navigation.

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