Making Personal Assistance Services Work for People with Disabilities

1. Making Personal Assistance Services Work for People with Disabilities MIG/DMIE Employment Summit April 23, 2008 New Orleans, Louisiana

3. Work Opportunities Reward Kansans (WORK) Supports that Improve Independence and Employment

4. What is WORK • Package of services to support employed people with disabilities who need Personal Assistance Services to go to work or increase current hours. • Cash and Counseling Model –goes one step beyond self-direction. • Must be eligible for the Medicaid Buy-in (Working Healthy)

5. Unique Features • More choice and options than traditional HCBS services in Kansas • Provides ability to work more and save more $ • More freedom to control who provides services, and how funds are spent (e.g. wages for PAS).

6. WORK Eligibility • Employed FICA/SECA payments • Kansas resident • 16-64 years of age • SSA Disability determination • Earnings over $65/month and Federal Minimum Wage • Eligibility for the Physical Disability, Developmental Disability, or Traumatic Brain Injury Waiver or waiting list or demonstrate the same need for supports.

7. WORK Services • Personal Attendant Services • Assistive Services • Independent Living Counseling

8. Personal Assistance Services • Funded via monthly allocation • Based on hours of care determined during the assessment • Can choose to use PAS or alternative to PAS and are provided at home and worksite • Can choose to use fiscal manager or be their own (with training) • Can choose to self-direct or agency-direct services

9. Examples of Alternatives to PAS • Lawn service • Meals on Wheels • Public transportation cost • Microwave oven • Top loading dryer

10. Assistive Services • Defined as any item , piece of equipment, or environmental modification, which is used to increase, maintain, or improve independence, employment, and/or health and safety.

11. Some approved uses for Assistive Services • Unique modifications to a van • Electric power lift • Electric generator • Lift chair • New remote control for van lift

12. Independent Living Counseling • Consumers who feel they can coordinate their services without the assistance of an ILC have the option to do so • KHPA reserves the right to require that consumers use an ILC if they have concerns about a consumers safety or health.

13. WORK Enrollment • Program began July 1, 2007 • Anticipated 50-100 enrolled during first year • Slow process to set up WORK • Enrollment December, 2008 • Working Healthy 1,019 • WORK 18 • Enrollment April, 2008 • Working Healthy 1,025 • WORK 50

14. WORK Enrollment(Allocations sent at the beginning of each month)

15. WORK Allocations • WORK consumers have varying levels of need. • Lowest cost - 24 hours per month, $344.00 allocation per month • Highest cost – 476 hours per month, $6,311.00 allocation per month • Average cost plan - $1,880.00 per month

16. Barriers Encountered • Slow enrollment of providers • Not business as usual • Slow enrollment of beneficiaries • Wanted to see how this would work for others before enrolling • Unique features of the program seemed difficult to understand • More training • Eligibility workers • IL Counselors • Consumers

17. Positive Outcomes Reported • More independence and choice regarding self vs agency direction • Ability to purchase things with their wages that are needed and wanted • Employer reports receiving the best from their worker

19. Serving People with Mental Health Disabilities in Utah’s EPAS ProgramCognitive and Behavioral Cuing Carol Ruddell Project Director, Work Ability Utah Work Ability Utah Utah’s Medicaid Infrastructure Grant CMS #11-P-92406-8/04

20. EPAS Participants Numbers of Participants • Currently 89 active participants • 239 applicants since 7/01/03 Disabilities • Self report by applicant and / or • As noted by clinician completing MDS-HC and/or BSI

21. Participant Demographics • Developmental Disabilities current 44, cumulative 116 • 4 Traumatic or Acquired Brain Injury current 4, cumulative 27 • 24 Mental Illness or Psychiatric Disability current 24, cumulative 59 • 13 with Physical Disability current 13, cumulative 37

22. State Plan Amendment • Have a disability • Be eligible for Medicaid (including buy-in) • Gainfully employed or promise of a job, in an integrated setting • Work at least 40 hours per month • Need personal assistance to work

23. EPAS Services “Services include physical assistance and cognitive cuing to direct self-performance of necessary activities.” • Activities of daily living • Instrumental activities of daily living

24. Eligibility & Services Process • Assessment: • MDS-HC (Minimum Data Set – Home Care) • BSI (Brief Symptom Inventory), a supplemental tool • Interview with Specialist • Determination made • Plan Developed • Personal Assistants hired • Services begin

25. Cognitive and Behavior Indicators • Assessment: • MDS-HC (Minimum Data Set - Home Care) • Section B Cognitive Patterns • Section E Mood and Behavior Patterns • BSI (Brief Symptom Inventory) • General Stress Indicator • Anecdotal information from interviews with assessor (LCSW or RN) • Interview with EPAS Specialist • Collateral information shared by family, caregivers

26. Cognitive and Behavioral Cuing for Daily Decision Making • Decision making and initiation of independent living and daily activities • Cognitive remediation: cuing assistance with concentrating on specific tasks, memory recall • Behavioral assistance: acknowledgment of feelings and cuing with appropriate expression of emotions related to passivity and/or frustration tolerance • Communication cuing

27. Decision Making and Initiation of Independent Living and Daily Activities • When to get up to have meals • Which clothes to wear • Reminder to take breaks at work • Reminder to wash hands • Reminder to eat meals

28. Cognitive Remediation:cuing assistance with concentrating on specific tasks, memory recall • Reminder to take medications • Affirming pill box accuracy • Reminder to set alarm • Scheduling public transportation and/or paratransit

29. Behavioral Assistance: acknowledgment of feelings and cuing with appropriate expression of emotions related to passivity and/or frustration tolerance • Problem solving of coworker interactions • De-stressing of situation • Reminder to cease inappropriate social behaviors

30. Communication Cuing • Cuing in socially appropriate verbal communication • Interpretation of actions or intentions • Debriefing of work relationships

31. Workplace Examples Cognitive and Behavioral: • Stress/communication debriefing • Discussion of emotional situation • Prevention of quitting due to frustration • Managing behaviors and communication • Direct Personal Care: • Uniform dressing • Personal hygiene / toileting

32. Cuing and Reminders • Face to face • Phone call • Text message • Watch alarm • Email • Calendar alarms • Other electronic communication

33. Coordinating Personal Assistance Services and Supported Employment Scott Holladay Arkansas MIG Project Director National Academy for State Health Policy (NASHP)

34. State Plan PAS Services Personal Care (agency services) Revised 10/1/2007 to include employment-related services Independent Choices (consumer-directed) Cash-and-counseling model Also includes employment-related services

35. PD waiver -- attendant care Consumer-directed Location not restricted Waiver amended to add Buy-In, but not implemented yet DD waiver – habilitation services Location not restricted Waiver amendment adding Buy-In pending Waiver PAS Services

36. Hands-On Care Vs. Cuing Personal care – hands-on help for individuals with physical dependency need Habilitation – teaching, including cuing of tasks, but not hands-on help DD waiver includes habilitation services, but not hands-on care

37. Supported Employment VR and Medicaid supported employment were seen as mutually exclusive Limited provider networks for both services Both services underutilized Result: most individuals with DD stuck in segregated settings

38. VR Supported Employment VR requires provider commitment to provide extended services after closure Extended services intended to maintain job stability – little funding available Individuals with DD may need more intensive supports VR objected to full-time direct service workers (DSW) after closure

39. Work group examined support needs Cuing Communications Behavior modification Help with ADLs

40. Discussion of support needs paved the way for final agreement VR did not object to help with ADLs, or most other supports VR did object to hands-on help with job tasks after closure Other parties agreed

41. Consensus on services & successful closures: Individuals must be able to perform all job duties independently at time of closure Job coaching fading out May still use occasional cuing of job tasks after closure, and May use full-time DSW for behavior modification, communications, ADLs

42. VR-DD Agreement Supported Employment Phase 1 – VR supported employment from assessment thru stabilization and closure Phase 2 – Waiver supported employment for long-term supports Other Medicaid supports can be used in either phase – personal care, waiver habilitation

43. Advantages Meet full range of individual needs Serve individuals not enrolled in waivers Supplement waiver services with State Plan services for additional hours More services = more provider agencies= more capacity and choice Option of consumer-direction

44. Disadvantages Seems more complicated More trouble to bill for multiple services

45. Lessons Agencies may use different terminology Carefully examine service needs Matching service needs with appropriate services may help overcome obstacles underfunding benefit limits restrictive service definitions

46. Alternate approach CMS Core Definition for Waiver Supported Employment The Guidance section states: Personal care/assistance may be a component part of supported employment services but may not comprise the entirety of the service.

47. Other disabilities Individuals with other disabilities will also benefit from coordinating services

48. For more information: Scott Holladay 501-682-8510 scott.holladay@arkansas.gov Betsy Barnes 501-683-6251 betsy.barnes@arkansas.gov