Texas’ Money Follows the Person Addressing Barriers to Successful Community Placement

1. National Home and Community Based Services Conference Atlanta, GA Texas’ Money Follows the Person Addressing Barriers to Successful Community Placement Marc S. Gold Texas Department of Aging & Disability Services Dena Stoner Texas Department of State Health Services September 27, 2010

2. TexasDemographics • Population: 25,373,947 (2010) • Counties: 254 • Regional Divisions: 11 • Nursing Facilities: @1,196 • ICFs/MR: 868 • Local Mental Health Authorities: 39 • Local Mental Retardation Authorities:39 • Area Agencies on Aging: 28 • Centers for Independent Living: 26 (164 counties)

3. 2010 Population Statistics • Nursing Facility: 55,000 • ICFs/MR: @10,300 Interest Lists • CBA: @34,050 -- Wait time: 1-2 years • STAR+: @5630 -- Wait time: 1-2 years • MDCP: 18,113 -- Wait time: 3-4 years • CLASS : 32,121 -- Wait time: 3-4 years • HCS: 45,884 -- Wait time: 4-5 years

4. Fundamental Issues • Texas has stringent criteria for admission • Interests Lists: 139,929 (probable eligibility (93,419) • Fixed Waiver Services Arrays • Large institutional ICF/MR structure

5. Waivers: Background Information • 1915 (c) waivers : • Nursing Facility: • Community-based Alternatives (CBA) • STAR+PLUS • Medically Dependent Children’s Program (MDCP)

6. Waivers: Background Information • 1915 (c) waivers : • ICF/MR: • Home and Community-based Services (HCS) • Texas Home Living • Community Living Assistance and Support Services (CLASS) • Deaf-Blind Multiple Disabilities

7. PromotingIndependence: History • June 1999: Olmstead Decision • September 1999: Governor George W. Bush’s Executive Order GWB 99-2 (1999) • June 2001: Texas Senate Bill 367, Rider 37 Texas Money Follows the Person

8. PromotingIndependence: History • Governor Rick Perry’s Executive Order RP-13 • TX Health and Human Services Consolidation • June 2005: House Bill 1867 • 2007: CMS’ MFP National Demonstration

9. Interagency Collaboration • Promoting Independence Advisory Committee (1999) • 2004: Health and Human Services Consolidation • Community Transition Teams • Housing and Health Services Coordinating Council (2009) • Several interagency councils on children • Interagency council on behavioral health transformation (2007)

10. Waiver Services • NF: services most used: • Adaptive Aids/DMS • Medical Supplies • Nursing Services • Attendant Services • HCS: services most used: • Dental • Day habilitation • Nursing • Residential Support

11. MFP and Priority Populations • MFP and nursing facility populations • Priority Populations and Intermediate Care Facilities for Persons with MR

12. MFP Statistics (August 31, 2010) • More than 21,000 individuals have transitioned from Texas Medicaid-certified nursing facilities • More than 8,000 individuals remain active in the community • 0-21 years of age: 2,046 children • 22-44 years of age: 9 percent • 45-64 years of age: 34 percent • 65-74 years of age: 20 percent • 75-84 years of age: 22 percent • 85+ years of age: 15 percent

13. MFP Statistics • 56 percent: female • 44 percent: male • 39 percent living with a family member 24 percent living in assisted living 32 percent living alone 1 percent living in adult foster care 3 percent with other waiver individual 1 other • Retention Rates: @95 percent

14. PriorityPopulations • Over 3,000 from nine or more bed private ICFs /MR and State Supported Living Centers • Individuals with complex medical/behavioral needs • Placement of choice: HCS-Residential

15. Barriers to Relocation • Long-term institutionalization • Information/knowledge of options • Co-occurring behavioral health issues • Lack of a statewide provider base to serve individuals with complex needs • Stabilized direct services workforce • Lack of rural service providers / transportation

16. Barriers to Relocation • Health and welfare concerns • Family/guardian concerns • Personal fears • Provider liability • Loss of community supports • Service array flexibility • Lack of housing

17. Barriers to Relocation • Coordination of services/SSI address change • Criminal History Checks • Home Modifications • Durable Medical Equipment

18. Communication: NF population • Relocation Specialists • NF Ombudsman and Social Workers • Minimum Data Set, Section Q • Developing new PASRR process • Community Transitions Teams • Aging & Disability Resource Centers • Family Councils

19. Communication: IDD population • Community Living Options Information Process • Community Living Options

20. Family/Guardian Concerns • Family concerns/resistance • Guardian issues • Physician resistance

21. Relocations Contractors • Nine catchment areas: • Centers for Independent Living • Area Agency on Aging • Case Management activities: • Pre-relocation services • Outreach/Education • Facilitation/Coordination • Housing Navigation and Supports • Coordination with local organizations • Post-relocation services • Coordination with managed care

22. MFP Demonstration • NF and ICF/MR populations • Behavioral Health project • Housing Initiatives • Overnight supports • Post-relocation Services • Voluntary Closure of private ICFs/MR • 1,599 individuals from NFs • 1,400 individuals from ICFs/MR • Met all benchmarks in July 2010 and now exceed: 3,113

23. MFP Behavioral Health Pilot • Bexar County (2010 expansion in progress) • Goals: • Transition adults with mental health and/or substance use disorders from NFs to the community and help them be successful • Improve services and supports in the long- term care system for people with mental health and substance use disorders

24. A True Collaboration • DADS (long term care) operates the overall MFP Project and provides relocation assistance. • DSHS (state mental health and substance abuse) operates the MFP BH Pilot. • The Local Mental Health Authority provides the BH Pilot services. • HHSC (State Medicaid) provides community-based long term services and supports through HMOs. • UT Health Science Center in San Antonio provides technical assistance, training and evaluation.

25. Collaboration in Action

26. Behavioral Health Pilot Services • Substance abuse / dependence treatment services (individual and group) • Cognitive Adaptation Training (CAT) • Pilot services are closely coordinated with acute and long term services • Pilot services are available six months prior to discharge from the NF and up to 365 days after discharge

27. Substance Abuse / Dependence • Individual and group counseling, including specialized groups • Peer Support • Linkage to community resources

28. Cognitive Adaptation Training • Evidence-based service, recovery-oriented • Provides assistance and simple environmental modifications to help people establish daily routines, organize their environment and function independently • Uses motivational interviewing to facilitate the person’s initiative and independence • Coordinated with HCBS services

29. CAT Intervention: Organization Apathy Disinhibition Mixed

30. Did I take my medication today? CAT Intervention: Medication

31. Behavioral Health: IDD • Positive Behavior Management • New project to explore including more intensive behavioral health services

32. Housing • State Housing Agency (TDHCA) • Public Housing Authorities • Disability Advisory Workgroup • Housing and Health Services Coordinating Council • Transition Assistance Services/ Transition to Life in the Community

33. Texas Dept. of Housing and Community Affairs • Grants to local agencies • Tennant Based Rental Assistance – 24 months (30% of income for rent). • Amy Young Barrier Removal Program – $15,000 w/Additional $5,000 • Project Access Vouchers • Only available for NF and ICF/MR relocations • From 65 to 100 on January 1, 2011 • 80 for non-elderly disabled (<62) • 20 for 65+ • Resident only pays 30% of adjusted gross income for rent and utilities

34. Local Housing Programs • Housing Voucher Programs • Relocation contractors work with state and local Public Housing Agencies (PHAs) to assist individuals find affordable, assessable, and integrated housing. • Local Public Housing Authorities - Housing units and Section 8 Vouchers • Resident only pays 30% of adjusted gross income

35. Health and Welfare • Individual Responsibility Agreement • Overnight Companion Services • Working with provider base to serve individuals with complex needs

36. Workforce • High turnover of community-based direct service workers • Consumer Directed Services • Workforce Advisory Council: e.g., Realistic Job Preview • Major issue: reimbursement

37. MFP Demonstration - New Projects • Behavioral Health Expansion • Dedicated staff to focus on workforce • Housing navigators • Staff to focus on individuals leaving large ICFs/MR • Creating specific databases • Ongoing training

38. The Future • New Money Follows the Person Demonstration funding opportunities • Waiver service array • HUD Notice of Funding Availability: additional Section 8 type vouchers

39. The Future • Working with provider base • Managed Care • Institutional diversion programs: risk slots and community living program • Specialized waivers • Children’s efforts

40. Contact Inf ormation Marc S. Gold Director, Promoting Independence Initiative 512.438.2260 marc.gold@dads.state.tx.us www.dads.state.tx.us/business/pi/index.html Dena Stoner, Senior Policy Advisor 512.206.4851 dena.stoner@dshs.state.tx.us