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Texas: Self-determination with Consumer Directed Services

National Academy for State Health Policy Reforming State Long-Term Services and Supports through Participant Direction. Texas: Self-determination with Consumer Directed Services. Marc S. Gold Texas Department of Aging and Disability Services October 5, 2010.

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Texas: Self-determination with Consumer Directed Services

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  1. National Academy for State Health Policy Reforming State Long-Term Services and Supports through Participant Direction Texas: Self-determination with Consumer Directed Services Marc S. Gold Texas Department of Aging and Disability Services October 5, 2010

  2. Consumer Directed Services (CDS) History • 1997: House Bill 2084: pilot model of • participant direction • 1999: Senate Bill 1586; expand CDS option • to Medicaid programs and established a • CDS stakeholder workgroup • 2001: CDS added to the Medicaid waivers • 2004: Consolidation of Human Services • 2010: CDS option in all waivers, state plan • and managed care programs

  3. Long Term Services & Supports Program • Waivers: • Older and Physical Disabilities • Community-based Alternatives • Medically Dependent Children Program • STAR+ (managed care) • Intellectual and Developmental Disabilities • Home and Community-based Services • Deaf-Blind Multiple Disabilities • Community Living Assistance and Support • Services • Texas Home Living • State Plan Programs: Attendant Services • Primary Home Care • Community Attendant Services • (b) attendant services

  4. What is Texas CDS? • Not “cash and counseling” • Mechanism to control hiring of selected • direct service workers and licensed staff • Service budget determined by agency staff • Limited budget flexibility: determine pay • rate within service rate set by state • Texas CDS is not: • Cash option • Service provision by legally liable adults • (spouse/parent) • “Individual goods and services”

  5. Texas 2010 • All individuals, across disabilities • and regardless of age have the option • to use CDS • Statutory Authority • 1915 (c) waivers • 1915 (b) waivers (managed care) • 1915 (j) state plan amendment (DRA • 2005) TX: attendant programs • No screening tool: self-determination

  6. Available Services through CDS • All programs: Personal assistance • services; habilitation and respite • Selected waivers: Nursing and • physical/occupational/speech therapies • Texas Home Living: All services

  7. Support Services to CDS Model • Financial Management Services (FMS) • payroll, deposit taxes and file tax • reports • $202/month in waiver program • $110/month in attendant programs • Support Consultation • Assistance and training: coaching the • individual how to interview/hire • $15.37/hour (from overall budget)

  8. Getting the Word Out • Case managers or service coordinators • provide information about the CDS option • at program enrollment and annually upon • service review • Information includes an overview of the • CDS option, employer responsibilities, FMS • provider responsibilities as well as • benefits and risks of using the CDS option

  9. Individual Responsibilities • Serve as employer • Recruit and hire services provider • Determine the work schedule • Determine the wage rates and benefits • Provide initial and ongoing training • Approve services provider timesheets • Handle conflicts • If necessary, terminate provider

  10. Budget and Spending Flexibility • Budget based on approved service plan • Any budget change must be proceeded by a service plan change • Wages determined within the rate established by the state • Budget allows employers to purchase employer-related supports: advertising costs, fax machine for sending time sheets, background checks and training for attendants (not individual goods/services) • 90% of budget must be allocated to service provider pay and benefits

  11. Utilization: 2008-2010

  12. Factors in Increase Usage • Addition of CDS to waiver program (HCS; • MDCP) • Expansion of managed care to urban areas • within Texas

  13. Population Differences • 49% of participants with related conditions • in CLASS waiver program • 3% of participants with intellectual or • developmental disabilities in HCS waiver • Less than 1% participants with physical • disabilities and those who are aging in CBA • 33% of parents of children with special • medical needs MDCP waiver program

  14. Fee-for-Services vs. Managed Care • Less than 1 percent in fee-for-service programs for individuals who are older or with physical disabilities • Three percent for same population in managed care

  15. Factors Impacting Usage • Elderly too ill to manage self-direction • Lack of informal support to help with self- • direction • Independent case managers versus agency • case managers • Conflict of interest when case management • provided by program provider

  16. Quality Assurance/Improvement • Data collected from the: • Personal Experience Survey • National Core Indicators • Those who use CDS reported they: • required less medical attention • required less support to prevent • disruptive behavior • felt safer in their homes • were more satisfied with their lives • felt less lonely

  17. Cost Effectiveness Studies • 4 studies, however mixed results with • inconclusive data • Trend data indicate: • Utilization of services increased with • CDS • Few hospitalizations and return to • nursing facility

  18. Strengths/Considerations • Strengths • Available to all individuals served by • Texas’ long-term services system • Operates under a single set of • administrative rules; consistency • Considerations • Ties CDS to specific waiver and rule • requirements such as service plan • developments/provider requirements, • case management or service coordination • Limits budget flexibility

  19. Workgroup Recommendations • Develop and implement outreach activities across TX to increase awareness and understanding of the benefits of the CDS • Establish a certification process for CDS Agencies (CDSAs) to improve quality of services and ensure cost-effective oversight • Make workers’ compensation insurance affordable for workers • Create a budget neutral, cross disability, self-determination pilot waiver in at least one rural and one urban site

  20. Future Considerations • Service Responsibility Option • Self-determination Waiver • Addition of individual goods and services • Require certification • Regional “supra” contract role • Increase responsibilities of support advisors

  21. Contact Information 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 Elizabeth Jones, Ph.D., CDS Specialist 512.438.4855 elizabeth.jones@dads.state.tx.us

  22. Websites • CDS Option: • http://www.dads.state.tx.us/providers/CDS/ • index.cfm • TX Administrative Code: Title 40, Part 1, Chapter 41: • http://www.dads.state.tx.us/providers.CDS/ • Ch41CDSJan2009.pdf.

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