California & New York Developmental Disabilities Systems

1. California & New York Developmental Disabilities Systems Similarities * Are the country’s largest developmental disabilities services systems * Progressed from reliance on institutional care to community based services * Increased developmental disabilities spending dramatically in the last twenty-five years * Serve large numbers of individuals on the Home and Community Based Service Waiver

2. California and New York Developmental Disabilities Systems Differences * Percentage of MR/DD funding supported by the Home and Community Based Service waiver * Cost per Home and Community Based Service waiver participant * Use of Federal Medicaid Funds * Fiscal Effort * System’s stability and potential for growth

3. What Can Be Learned From the New York Experience? • Many factors contributed to New York’s success in quality service provision, system stability and accessing federal funding - not the least of which were PARTNERSHIPS. • Parent to parent and parent to government caused the creation of an executive level agency (Office of Mental Retardation and Developmental Disabilities) in 1978 to support the State’s commitment to its citizens with developmental disabilities.

4. A Culture of Inclusion • OMR/DD established a culture of inclusion. Partnerships were highly valued. • All stakeholders were involved in the development of its policies, program and fiscal plans, and implementation strategies.

5. Consumers, parents and families State ARC and its Chapters State UCP and its affiliates Other major provider associations State managers, including the equivalents of Regional Center Executive Directors as well as headquarters staff Three State workforce unions, including 5 separate bargaining units Advocacy groups including self-advocates New York City and County MH, MR and Alcoholism Boards Relevant state agencies, including Division of the Budget, Department of Social Services (single state agency for Medicaid) Fiscal and Program Committees of the State Legislature • Key stakeholders included:

6. Policy Directions New York developed a clearly stated policy directions for service provision. BEDROCK BELIEFS! * Offering quality services in both institutional and community care * Supporting and valuing the work of both state employees and private sector workers in meeting service needs * Institutional Downsizing * Developing new services on a yearly basis to meet the needs of individuals leaving its institutions and individuals in need of services who are not institutionalized * Individualizing services to meet consumers’ needs * Supporting families in meeting the needs of their family members with disabilities in their homes * Identifying all New Yorkers who met the eligibility criteria for services and planning for addressing their needs. * Closing developmental centers - beginning in the late 1980’s Decisions driven by quality of services and economic considerations Funds insufficient to support both systems Decision was made to invest in the Community System

7. Fiscal Strategies Fiscal strategies were developed with two purposes in mind: Provide a stable funding for existing providers of service and Increased services through utilization of the Federal Medicaid Program. How was this accomplished? * OMRDD invested in up-front costs to pursue Medicaid funding Dedicated staff to pursue Federal Medicaid options. Used the services of expert consultants when necessary. Dedicated staff to programmatic and fiscal implementation of the Medicaid service * Federal dollars were reinvested from the institutional program to the community program with the concurrence of CMS’ Region 2, the single state Medicaid agency, state Division of the Budget, the Legislature and the Governor. * Federal funding accounted for an increasing proportion of total spending over time.

8. Multiple Medicaid funding programs and services have been accessed. * ICF/MR, ICF/DD, and Day Treatment * Clinics for Medical and Ancillary Services * Home and Community Based Service Waiver * Katie Beckett Waiver * Personal Care Options * Habilitation Services in your equivalent of Family Foster Agencies * Care at Home Waiver * Transportation services In big systems like NY and CA, you can almost always find a cohort of individuals who can benefit from various Medicaid services.

9. Program and Fiscal Strategies Program and Fiscal strategies were used to adequately fund services, and to support the state and non-state workforce: * Cost of Living Adjustments and trending of rates for Medicaid services were utilized for agency operated programs * Increases in the state provision of community services allowed state institutional workers to retain their jobs. Workforce reductions achieved through fewer backfills into targeted jobs, early retirement initiatives, administrative consolidations, and other strategies that limited reductions through layoffs * Recognized and provided for salary differentials for high cost areas of the state.

10. * Partnerships were a key to making these strategies work. * Services were delivered by both state and private sector employees. Both sectors played a role in “doing it right” so that federal revenues once accessed could be maintained. * Every strategy to increase the use of Medicaid requires hard work to develop it, to implement it and to monitor it.

11. Executive and Legislative buy-in was obtained. * Yearly budget requests were supported by concrete information on the needs for service * The agency’s track record for developing new or different services to meet needs was highly credible. * Clear information on the funding levels required to support needed to maintain existing community services * OMRDD Executive staff and other key stakeholders interacted on a regular basis with Executive and Legislative MR/DD Committee staff to ensure that programmatic and fiscal strategies were understood * OMR/DD demonstrated fiscal and quality of service accountability.

12. Can the experience in New York offer areas of exploration? Using the power of its partnerships, California can * Continue to increase Federal Medicaid participation. * Develop and implement strategies to transfer funds from institutional services to community services as the number of individuals served in its institutions decreases. * Further involve stakeholders in the development and promotion of a policy direction for the future of services to Californians with disabilities. * Demonstrate that expanding total resources for Californians with disabilities through increased utilization of Federal Medicaid matching funds is a good investment in the future of California.