Olmstead Progress Report

THREE-YEAR OLMSTEAD V L.C. PROGRESS REPORT

October 2002

National Association of Protection and Advocacy Systems, Inc.
Training and Advocacy Support Center
900 Second Street, NE, Suite 211
Washington, DC 20002
Voice: (202) 408-9514
Fax: (202) 408-9520
www.napas.org

 

TABLE OF CONTENTS

I. INTRODUCTION

II OLMSTEAD-RELATED FEDERAL GRANTS ARE DIRECTING STATE IMPLEMENTATION EFFORTS

  1. Centers for Medicare and Medicaid Services "Systems Change" Grants
  2. Center for Mental Health Services "National Coalition to Promote Community-Based Care" Grants
  3. Joint Departments of Justice, Education and Labor Olmstead Training Grants
  4. Department of Health and Human Services Grant To Study Recent State Long Term Care Policy

III PROMISING STATE AND CONSUMER ACTIONS TO IMPLEMENT THE OLMSTEAD DECISION

IV CONCLUSION

 

3rd YEAR OLMSTEAD V L.C. PROGRESS REPORT

I    INTRODUCTION

It has been three years since the Supreme Court issued its decision in Olmstead v L.C., 119 S.Ct. 2176 (1999).  As in past years, NAPAS has attempted to measure progress toward compliance with the decision.  In the past we have measured state efforts to comply.  This year, however, the NAPAS Progress Report focuses on federal efforts to assist states in complying with the Olmstead v. L.C. decision[1]. The second half of this report, similar to progress reports in past years, identifies some promising state and advocacy efforts[2].

Much of the federal governments effort's to assist states in implementing the Olmstead decision has come in the form of grants available to states on a competitive basis.  The importance of these federal grants can not be understated since many states appear to be limiting their Olmstead implementation efforts to only those activities funded by these grants. For this reason, disability advocates must carefully monitor how the grants are being implemented and whether the states' stated goals are being achieved.

Unfortunately, the details about these federal grants are not well known by disability advocates.  In fact, a common thread running through all of our research compiling this report was a lack of awareness of and coordination between Olmstead implementation initiatives at both the federal and state level.  Hopefully, this progress report will clarify the opportunities, as well as limitations, created by these federal grants; armed with this information, advocates can seek additional federal assistance for unmet needs in the future.

II  FEDERAL OLMSTEAD-RELATED GRANTS ARE DRIVING STATE IMPLEMENTATION EFFORTS

Researching federal Olmstead -related initiatives that provide funding for community integration required numerous calls to numerous grantees and federal agencies.  In our research it became clear that grantees were only minimally coordinating, if at all, with grantees working on other Olmstead related grants reaching out to the same populations.  It is not necessarily a problem that federal grantees working on Olmstead initiatives were not coordinating.  In fact it may not be possible given that Olmstead implementation is a huge undertaking that could benefit from funding assistance from more than just one, two, or even ten federal agencies.  The lack of coordination does, however, have important implications for disability advocates, who will need to work harder and in more arenas in order to influence and evaluate these initiatives[3].

The impact of the grants described in this section are still too new to yield statistics on their success or lack thereof.  Nevertheless, advocates for the disability community should seek out information on what grants were funded in their state, whether they feel adequately represented on the advisory committees, and what grantees have promised to be doing with the money.  Obtaining this information will hopefully bring about greater input and oversight from consumers.

A   Centers for Medicare and Medicaid Services "Systems Change" Grants

In December 2000, during the final days of the Clinton Administration, Congress earmarked $50 million dollars in the Labor, HHS Appropriations Bill to fund Real Choice Systems Change Grants.  The goal of the grants is to establish specific action steps and timetables to achieve enduring system improvements and to provide long term services and supports to eligible individuals in the most integrated setting appropriate.  In September 2001, the Bush Administration announced that the Centers for Medicare and Medicaid Services (CMS), a division of HHS, was awarding $64 million to 37 states and one territory, and in 2002 awarded an additional $55 million in new grants to 21 states and 2 territories. The grants are broken down into four types: Nursing Facility Transition grants, Real Choice Systems Change grants, Technical Assistance Exchange grants, and Community-Integrated Personal Assistance Services and Supports grants.

Grants were awarded based on the rank of scores awarded by a review team. Consumer involvement was not a criteria for the review teams.  However, CMS has said that consumers, family members and disability advocacy organizations represented a significant portion of the grant reviewers.  Other grant reviewers included HHS employees, community-based providers, representatives of institutions, and state employees from states not applying for grants. The review process was too time consuming to re-convene after only one year, so in 2002, the second round of funding was granted without competition to the states with the next highest rankings from the initial rankings given by the review team in 2001.

Responsibility for monitoring and assessment of the States' programs falls to the Research Triangle Institute (RTI), which received a special CMS Process Evaluation grant for this purpose.  The RTI evaluation program is to run for three years, and focuses on implementation, rather than outcomes.  In other words disability advocates should not look to this program to evaluate involvement of consumers, consumer satisfaction, or the impact of grant activities.  RTI has already completed its first report, a comparative analysis of State proposals selected to receive grant money.  The report is still under review by CMS and will probably be released by mid-October.  Very few of the systems change grantees or consumer advocates we spoke to were aware of the RTI Process Evaluation grant or its upcoming report, and it is not listed on the CMS list of grant programs and recipients.

The purposes of each of the four types of HHS Systems Change grants, along with the general characteristics of successful State proposals for grant money, are set out below. Information on specific grant proposals was taken from the "Compendium of the 2001 Systems Change Grants for Community Living" ("The Compendium"), put out by CMS.  The Compendium is available at https://www.cms.gov/CommunityServices/30_RCSC.asp This same website includes a listing of states awarded the 2002 systems change grants along with funding amounts.

a)   Nursing Facility Transition/Access Housing Grants

 A collaborative effort between HHS and the Department of Housing and Urban Development (HUD) is the nursing facility transition grant, which provides States funds to transition people from institutional living arrangements to community settings.  CMS awarded $11.1 million in 2001 and $9 million in 2002.  Each state was eligible for grants, ranging from $300,000 to $1,000,000.  CMS gave the following examples of the types of activities that States might support with these funds: staff resources, transitional supports, self-direction and consumer management infrastructure, improvements to on-going supports, and interagency collaboration.

In 2001 seventeen nursing facility grants were awarded.  About half of theses grants targeted a particular sub-group of people in nursing facilities, such as Maryland's program, which focuses on those under the age of 65.  The other half of the grants focused on all nursing facility residents regardless of disability type or age. Only a handful of states included in their grant applications individuals "in danger of" being placed in a nursing facility as a specific target population.  Technical assistance/training and coordination with other agencies were components of almost all of the proposed programs, while less than half of the programs had a monitoring component.  Seven programs took the interesting approach of setting as a goal a specific number of people to transition from a nursing facility to a more integrated setting.  Alabama, for example, planned to help 25 people with its program.  Only four states included in their proposed programs a plan for personnel increases.  In 2002, eleven more systems change grants were awarded.

Georgia's program offers a good example of the typical Nursing Facility Transition grant proposal.  Run by DisABILITY LINK, the program utilizes five different subcontractors, and targets persons of all ages with disabilities currently residing in nursing homes.  With the help of the subcontractors and the Department of Community Health, DisABILITY LINK hopes to hire and train people to lead transition teams that will identify individuals wishing to transition to the community.  In addition, DisABILITY LINK works to expand current transition programs to include all those in need of transition services, and it develops resource committees statewide.

In 2002 an important addition was made to the nursing facility transition grants.  In addition to the State Program grants, Independent Living Centers were allowed to apply for partnership grants in order to create and maintain the infrastructure needed to implement the Nursing Facility Transition Initiative.  In 2002, five such grants were awarded to Independent Living Centers.

The New Jersey program is an example of a 2002 ILC "partnership grant."  Run by Resources for Independent Living, Inc. (RIL), grantees focus their efforts on trying to connect people who are just beginning the reintegration process with those who have already been reintegrated.  To achieve this end, RIL will establish mechanisms for information and referral, peer support, independent living skills, and advocacy.  The advocacy mechanism includes both systems advocacy, to assure that money expended by the government is expended to everyone who is supposed to benefit from it, and individual advocacy, teaching individuals how to advocate on their own behalf.

The Nursing Facility Transition grants were originally intended to be part of a larger initiative that included HUD's Section 8 Rent voucher program.  Under that program in 2001, HUD made available 400 "Access 2000" rent vouchers for use by eligible non-elderly individuals with disabilities.  The vouchers were allocated to local public housing authorities partnering with the responsible human service agency.  HUD envisioned eventually distributing 2000 vouchers depending on appropriations.  In 2002, however, Congress appropriated no money for the Access vouchers.  In its proposed 2003 budget, HUD has specifically asked Congress to either allow HUD to use 1000 existing vouchers for the Nursing Facility Transition initiative or to create 1000 new vouchers for that purpose.

b) Real Choice Systems Change Grants

The Real Choice grants make $50 million available to the States so that they can create the infrastructure and service options necessary for long-term community integration that allows people with disabilities to exercise meaningful choice about the services they receive.  In developing such programs, States are expected to partner with their disability communities in meaningful ways.  For example, in order to receive a Real Choice grant, each State must put together a Consumer Task Force, made up of a variety of people with disabilities or chronic illnesses who need long-term services.  Any proposal submitted by a State must be developed in collaboration with its Consumer Task Force.

Missouri's program is typical of those awarded grant money in 2001.  Awarded to Missouri's Department of Social Services (DSS), the "Flexible Choices for Independence" program also includes as a subcontractor the University of Missouri-Kansas City.  Program goals include streamlining the system to assure quick and easy access, fostering interagency coordination, and conducting research on small demonstration projects to identify best practices and projects that should be replicated.  To achieve these goals, DSS plans to develop resources for training on informed choices for a wide audience, study length of hospital stays and frequency of transfers, and develop a standardized application process and referral system.

Twenty-five Real Choice grants were awarded in 2001 and, as with the other Systems Change grants, the vast majority of proposed programs included subcontractors.  Target populations broke down into general (13), semi-specific (5), and specific (7).  Two-thirds of the proposed programs had a training/technical assistance portion, and almost as many had mechanisms in place for monitoring and assessment.  Eight of the proposed programs accounted for efforts to increase personnel, and three envisioned the need to catch people with disabilities before they are institutionalized.  While none of the proposed programs targeted a specific number of people to help, some states (e.g., Nebraska) are making a concerted effort to set uniform standards and practices with regards to data and resource management, so as to make the system more user-friendly.  Thirty States and Territories were awarded Real Choice grants in 2002; all received at least $1 million.

c) Community Integrated Personal Assistance Services and Supports Grants

The Personal Assistance Services (PAS) grants are designed to promote community-based programs that enable individual self-direction and self-management of services.  In addition to being more attractive to consumers because of its focus on individual choice, such an approach is thought to be more cost-effective. Examples of such programs include Self-Determination for People with Developmental Disabilities, Cash and Counseling, and the Independent Choices Initiatives.  Like the Real Choice grants, these grants focus on the creation of an infrastructure to ensure the continued success of these efforts.

The 2001 PAS Grants, ranging from $300,000 to $900,000, were awarded to organizations in ten different states.  Eight of the grant recipients used a subcontractor.  The programs' target populations can be broken down into three categories: general (4), semi-specific (1), and specific (5).  The general programs, such as Michigan's, focused on a wide range of people with disabilities.  Minnesota's program was semi-specific, in that it had a general focus with special consideration given to people of color.  The specific programs focused on one particular group of people with disabilities, such as people with developmental disabilities (e.g., Arkansas).  The common thread running through these programs was that, except for one, they all had a training and technical assistance component.  Surprisingly, only one of the programs accounted for an increase in personnel, and four programs had no monitoring/assessment mechanisms in place.  In 2002, eight $725,000 grants were awarded to organizations.

Montana's program is typical of the 2001 PAS grant programs.  Awarded to Montana's Department of Public Health and Human Services, Senior and Long Term Care Division, the program includes three subcontractors and targets consumers of all ages and disabilities.  Entitled Montana CHOICE, the program aims to develop a central mechanism for recruiting, screening, and training attendants to work across the home care network.  In addition, the CHOICE program intends to direct public relations efforts toward community education, and to develop a statewide website for attendant-training purposes.

d)  The National Technical Assistance for Evaluation Exchange and Process Evaluation

 This technical assistance project is considered a companion program to the Systems Change grants.  Its purpose is to facilitate the exchange of information between States regarding which approaches and programs have worked and which have failed. This exchange of information is expected to be especially important in helping various levels of government coordinate their efforts in providing services.

The 2001 Technical Assistance grants went to Independent Living Research Utilization (ILRU) and the Rutgers Center for State Health Policy.  Both ILRU and Rutgers each received one million eight hundred thousand dollars, so the total amount spent on the Exchange Collaborative in 2001 was three million six hundred thousand dollars.  The Rutgers Center and ILRU neither monitor nor assess what States are doing with their grant money; rather, they provide training and technical support for the States related to their new programs. Disability advocates and consumers are not the target of technical assistance; however, consumers can find information on the exchange Collaborative's website www.hcbs.org.

While the grant money was awarded separately, these are not truly separate programs.  Rather, the two organizations form an integrated management team, with responsibilities divided by splitting the States in half, based on the contacts each organization already has established in a particular State. For example, the Rutgers Center provides assistance to most of New England with the exception of New Hampshire, which ILRU handles due to its strong ties with that State.

In 2001, the Exchange Collaborative engaged in several activities.  First, it contacted each grantee individually to conduct a needs assessment.  The results of these assessments were shared with the grantees and numerous disability advocates who attended the Systems Change Conference sponsored by CMS in March 2002.  Second it developed a website, www.hcbs.org, to provide information and resources about other grantee activities and Medicaid and Medicare funding for home and community based services.  Third, it helped to coordinate the 2001 CMS Systems Change Conference.  Forth, it provided telephone and onsite technical assistance upon request from systems change grantees.  In 2002 the Collaborative plans to begin developing issue briefs, which will be posted on its website.

B   Center for Mental Health Services' National Coalition to Promote Community-Based Care

 In addition to the Systems Change grants discussed above, the Center for Mental Health Services is funding a National Coalition to Promote Community-Based Care.  The purpose of the Coalition is to assist states to develop or expand existing community integration plans that address the service needs of adults with serious mental illnesses, and children with severe emotional disturbances, who are institutionalized or at risk and could be more appropriately supported in the community.  The Initiative has several components.  First is to convene a Coalition of national disability advocacy groups and state mental health divisions who will develop resources in the areas of housing, health care, employment, transportation, community organizing, and children's issues.  These resources will be made available to state Olmstead coalitions. Second, the initiative supports a technical assistance team who provide onsite and telephone technical assistance to states upon request, provide training, issue papers and develop a website.  Third, CMHS is providing annual grants of $20,000 per year to State Mental Health Authorities to support efforts to build coalitions to promote community based care.  There is also an evaluation component of the initiative.

Every state applied for and received the $20,000 in 2001 and 2002.  Since the funding is minimal, most of the states are using it to supplement a larger initiative in the area of mental health.  Connecticut is typical of how these funds are being used.  While the working draft of Connecticut's official response to Olmstead does address mental health issues, many consumers, families, and advocates thought the area of psychiatric disabilities needed to be more fully addressed.  The primary use of this grant will be to see that recommendations of individuals with mental health needs receive a stronger emphasis.  Specifically, the Connecticut Department of Mental Health and Addiction Services will use this grant to establish anOlmstead Mental Health Advisory Council, comprised of consumers, families, and advocates, and will try to engage constituency groups not currently involved. Grant funds will be used to support consumer travel and conference expenses, website development for the dissemination of information, and contractual services to establish focus groups, provide written reports, coordinate meetings, and provide general support.

Accomplishments of the National Coalition and the technical assistance portions of the initiative in 2001 and 2002, include: 1) hosting two gatherings of the National Coalition; 2) developing a compendium of information about each grant funded; 3) compiling a resource for Olmstead planners entitled Overcoming Barriers To Community Integration for People with Mental Illness and a companion piece Overcoming Barriers to Serving Our Children in the Community; 4) maintaining a website at www.Olmsteadcommunity.org; and 5) preparing a community integration training manual and materials for consumers and state professionals in both English and Spanish.

There has been some concern among the disability community that this initiative may lead to fragmentation of Olmstead planning activities to include one plan for individuals with mental illness and a second plan for other individuals with disabilities.  The purpose of the grants, however, is the exact opposite.  In 1999 and 2000 many states were indicating that they were focusing Olmstead planning efforts on individuals in intermediate care facilities and to a lesser extent individuals in nursing facilities before they focused on residents of psychiatric facilities. The goal of the CMHS initiative was to bring more individuals with mental health needs to the planning process and hopefully jump start state efforts on behalf of individuals with serious mental illness.  Clearly, if advocates become aware that activities funded under the CMHS initiative are not coordinated with larger state Olmsteadimplementation efforts they should make it known that a major goal of the initiative is not to separate but rather to support collaboration.

C Joint Departments of Justice, Education and Labor Olmstead Training Grants

In 2001, the Departments of  HHS, Education, and Labor jointly funded an Olmstead training grant providing $400,000 to the Brain Injury Association and $400,000 to the Independent Living Research and Utilization Program to train a core group of cross-disability leaders and advocates.  The recipients of the training, in turn, are expected to work with their stateOlmstead planning task forces to develop a comprehensive, five-year plan for implementing and evaluating strong consumer-directed home and community-based services for persons with disabilities of all ages.

Five regional trainings, entitled Disability Advocacy in A Post Olmstead Environment, were held in Atlanta, Houston, Kansas City, Portland, and Hartford.  The majority of participants received a stipend to cover some of the expenses to attend these trainings.  Over 345 people received the training and overall gave them a good evaluation.  Trainings covered the following topics: 1) the Disability Advocate's Perspective; 2) Where We Are; 3) Medicaid HCBS and Long Term Care; 4) HCBS for Older Persons; 5) Access to Housing; 6) Moving into The Community; 7) the Role of State Medicaid Directors, State Legislators and Consumer Stakeholders; and 8) the Components of a Comprehensive Plan.  Many of the handouts from this training can be accessed at www.ilru.org/Olmstead/resources.

An important outcome of the training was that representatives from each state in attendance developed an "Advocacy Plan," which included information on 1) What Has Already Been Accomplished to Implement Olmstead; 2) community integration plans already in place; 3) grants the state has applied for related to Olmstead implementation; and 4) Future Action Steps.  Advocacy Plans developed during this conference can be obtained at: www.ilru.org/Olmstead/Advocacyplans.

Since follow up to the training was not a requirement of the grant it is hard to know whether individuals who attended the training are actually working on Olmstead planning at the state level, and it is hard to know whether the knowledge participants received is important to plan development and implementation. However, the website developed for individuals who received the training, which contains a section that allows individuals to post plans and updates at www.ilru/Olmstead/messageboard, seems to show that the training jump started several coalitions to work on Medicaid and consumer directed issues in their states.

In 2002 ILRU received an additional $400,000 to continue to maintain the website and to provide targeted technical assistance to coalitions that formed as a result of the training and others seeking this information . Additionally the grant is funding a series of webcasts on hot Olmstead topics such as: State Legislatures and the Olmstead Decision: What's the Latest? Community First: Issues and Strategies for Getting/Keeping People Out and Housing Options: Community Living and Assisted Living.  Lastly, the ILRU will be turning the materials distributed at the training and a video of the training into modules of different topics that can be used by state Olmstead planners.

D   Department of Health and Human Services Study of Recent State Long Term Care Developments and Policy Directions

"State Long-Term Care: Recent Developments and Policy Directions" is the first of two reports of an 18-month project funded by the Office of the Assistant Secretary for Planning and Evaluation of the U.S. Department of Health and Human Services. This report provides a thumbnail sketch of long-term care budgets, legislation and planning in the 50 states and the District of Columbia. It  focuses mainly on state legislation, expenditures and policy activity in fiscal year 2001 and previews fiscal year 2002.  In the summer of 2003, NCSL will publish a second report that will update subsequent long-term care budgets, planning and implementation strategies in the states.

The analysis in this report was derived from several sources, including:  responses to a NCSL long-term care expenditure survey sent to legislative fiscal offices in 2001;  FY 2000 and FY 2001 Medicaid long-term care expenditures reports compiled by Brian Burwell of MEDSTAT Inc., who uses HCFA 64 reports that the states file annually with CMS (formerly HCFA); state Web sites and state legislative reports; and a report for The Kaiser Commission on Medicaid and the Uninsured by Charlene Harrington, Medicaid 1915 (c) Home and Community-Based Waivers: Program Data, 1992-1999.

The preface to this report speaks volumes with its repeated reference to "tight budget constraints and growing concern about health-related expenditures".  Overall, state long-term-care accomplishments seemed more focused on low cost administrative actions rather than bold new demonstrations for funding community-based supports or moving people out of institutions.  For example, only one state reports creating a new HCBS option and only one state reports adding personal assistance services as a Medicaid state plan option.  On the other hand, State legislatures took a number of major actions to regulate nursing homes and assisted living facilities.

III PROMISING PRACTICES STATES AND ADVOCATES ARE USING TO ENFORCE THE MANDATE OF THE OLMSTEAD DECISION

This section highlights some of the efforts to remove barriers to Olmstead implementation.  The report does not attempt to identify all of the states that are engaged in similar efforts to the ones mentioned.  NAPAS would welcome individuals to identify promising practices which we could highlight on the Disability Rights Information/Community Integration page of the NAPAS website at (www.ndrn.org).  Another resource on promising practices is an August 8, 2002, CMS letter to state Medicaid Directors, which focuses on strategies available to states to assist individuals to avoid or leave unnecessary nursing facility placement.  Lastly, the HHS, Office for Civil Rights and plans to release a compilation of promising practices for implementing the Olmstead decision in the next six months.

C  "Money Follows The Person" From The Institution Into The Community

Texas received funding and legislative approval last year to begin moving Medicaid funding with the individual moving from a nursing facility. Rider 37 of the 2001 Appropriations Act states that:

It is the intent of the legislature that as clients relocate from nursing facilities to community care services, funds will be transferred from Nursing Facilities to Community Care Services to cover the cost of the shift in services.

Texas estimates that since September of 2001 over 323 people have moved from nursing homes into the community using nursing facility funding. The Texas Division of Health and Human Services administers the "money follows the person" program. One Texas administrator offered several reasons why the program got funded: 1) Texas has a 30% vacancy rate in its nursing facilities, which means the money need not be used for people on a waiting list and is free to move with the individual; 2) the bill passed as a "Rider" to the state Appropriations Act, meaning it was subjected to less agency and public scrutiny; and 3) the nursing home industry did not try to stop the bill.

Missouri began a similar program and disability advocates received estimates that since July 2000, over 60 people out of about 95 have moved from nursing homes, taking the money with them and putting it towards personal assistance services. Overall appropriations for the program are expected to be able to serve 53,000 people in the community.

Missouri, like Texas, used the state Appropriations Act as the vehicle for passing a "money follows the person" program. In Missouri, the program is tied to eligibility for the Medicaid personal care option. This works because in Missouri, all individuals eligible for Medicaid long-term care are eligible for the personal care option. The 2000 state Medicaid Appropriations Act states:

Individuals eligible for the Medicaid Personal Care Option must be allowed to choose, from among all the options, that option which best meets their need; and also be allowed to have their Medicaid funds follow them to whichever option they choose.

Unlike Texas, the nursing home industry in Missouri did organize and oppose this portion of the State appropriations bill.  Even though Missouri does not technically have a waiting list for nursing facility beds, the number of beds funded in nursing facilities had been steadily cut for a period of years prior to 2000. In order to make the bill less controversial, Missouri's past Governor, Mel Carnahan, added a provision increasing nursing home funding for direct care staff salaries and benefits. In accepting the increased rates, the individual members of the industry agreed to inform an individual eligible for or receiving nursing home care that they have the opportunity to have those Medicaid dollars follow them to the community. The Missouri Olmstead "plan" recommends that a similar program be allowed for people transitioning from intermediate care facilities. This option did not get funded in the last appropriations cycle.

*   Amending Nurse Practice Act Restrictions

 On July 1, 2002, South Carolina's Governor signed legislation that creates an exemption from the State's definition of "nursing" to allow people with disabilities to hire people of their own choice to provide self-directed attendant services. It also says that it is not "nursing" for other people to do things for individuals with disabilities that individuals would do for themselves if able.  The legislation, which began as S 977, ultimately passed as an attachment to another Bill, H 3817.  It allows nurses to train non-licensed personnel working in residential facilities to dispense certain medications by instruction, thus amending the Nurse Practice law which previously restricted this.

C  Allowing The Medicaid Buy-In

According to an April 2002 report by the National Conference of State Legislators, approximately 20 states (Alaska, Arkansas, California, Connecticut, Illinois, Iowa, Maine, Massachusetts, Minnesota, Mississippi, Nebraska, New Jersey, New Hampshire, New Mexico, Oregon, Pennsylvania, South Carolina, Utah, Vermont, and Wisconsin)  have approved and funded some version of a Medicaid buy-in option.  Under federal authority granted in 1997 and expanded through the 1999 Ticket to Work Act, states have the option of creating new Medicaid eligibility categories for persons with disabilities who work. Prior to the new authority, persons with disabilities who increased their incomes through work often lost their entitlement to Medicaid and with it such essential services as personal assistance and prescription drug coverage. To provide continued Medicaid coverage when persons with disabilities enter the workforce, states may now establish income and asset standards for this group that differ from other categories. If they wish, states may require newly eligible persons to share in the cost of Medicaid coverage ("buy-in") through premiums or other cost-sharing charges.

C  Identifying The Unique Barriers Facing Long-Stay Patients in Mental Health Facilities

New York has developed a task force to focus on long stay patients residing in mental health facilities.  The goal of the task force is to identify any unique characteristics among this population that may be contributing to their long institutional stays.  Once these characteristics are identified the task force will recommend additional supports and services to better enable discharge into the community.  For example, the task force may find that language barriers are reducing the effectiveness of mental health services offered to the individual.  With this information the task force can recommend increased access to interpreters, augmentative communication devices etc.  Another factor the task force will consider is the possibility that cultural differences are lessening the benefit of the supports an individual is receiving.   Once again they can recommend individual and systems change to reduce these barriers.

C  Using Section 8 Vouchers or HOME Tenant-Based Rental Assistance to Increase Affordable Housing for People with Disabilities

According to the Spring 2002 Edition of NIMBY, The Olmstead Factor:  Integrating Housing for People with Disabilities, several states have expanded their use of Section 8 vouchers or HOME tenant-based rental assistance to expand access to affordable housing for people with disabilities.  For example:

Alabama has implemented a new rental production program for people with disabilities that includes dedicated set-asides of HOME and Federal Low-Income Housing Tax Credits. Developers are encouraged to use these funds to create partnerships with public housing authorities (PHAs) willing to seek new Section 8 vouchers for people with disabilities from HUD.

Rhode Island's Thresholds program administered by Rhode Island Housing has linked capital funding for housing for people with mental illness to rental production strategies that include set-asides of units for people with disabilities in multi-family developments across the state. During the development process, project owners establish partnerships with local service provider agencies to facilitate access to supportive services desired by residents.

Both Oregon and Ohio which have strong track records in providing both state capital funding as well as state-funded "bridge" rental subsidies that are linked to Section 8 vouchers at partnering PHAs. In Pennsylvania, the housing finance agency recently implemented a housing production model using agency reserves to fund a set-aside of affordable units for people with SSI-level incomes.

Massachusetts is planning a Section 8 project-based initiative for people with disabilities that will be coordinated with state health and human services agencies. MassHousing, the state's housing finance agency, has also developed the Elder Choice program, a partnership between the Housing Finance Agency and the State's Medicaid program, which provides up to a 20 percent set aside of units in market-rate assisted-living projects for people receiving Medicaid-funded supportive services.

The NIMBY Report is published regularly and its editors encourage advocates and states to submit information about activities to promote access to accessible, affordable housing in the community to michaela@bazelon.org. Recent issues of NIMBY are available at http://www.nlihc.org/nimby/spring2002.pdf.

C  Supporting Olmstead Implementation With Private Foundation Funds

 

Under the auspices of The Robert Wood Johnson Foundation's Building Health Systems for People with Chronic Illnesses program, The Center for Health Care Strategies (CHCS) is funding a series of resources to assist with Olmstead implementation.  Resources developed thus far include (1) "The Americans with Disabilities Act and Community Integration: Understanding the Concept of Fundamental Alteration" published in May 2002  (2) "Defining "Reasonable Pace" in a Post-Olmstead Environment" published in April 2002  (3) "Olmstead and Supportive Housing: A Vision for the Future" published in December 2001 and (4) "An Analysis of Olmstead Complaints: Implications for Policy and Long-Term Planning" published in December 2001.  Each of these reports is available at www.chcs.org.

IV CONCLUSION

 Federal and state actions in response to the Olmstead decision continue to be a huge opportunity for disability advocates to advocate for systemic change in support of community integration.  This report shows that money is available to help states make this change.  However, without the disability community tracking these funds it will be impossible to measure its effectiveness.  Furthermore, states will continue to need funding assistance to achieve the mandate of the Olmstead decision.  The ability to track and show an impact from federal assistance thus far should only help in the future as advocates demand additional federal efforts to help states end unnecessary institutionalization and promote community integration.

With each year that goes by, federal and state attention to Olmstead implementation is likely to diminish.  It is, therefore, imperative that the disability community continue to bring the mandate of the Supreme Court's decision in Olmstead to the attention of state and federal leaders.  Disability rights advocates have been most successful when they have worked in coalition to get the attention of policy makers.  Advocates should continue working with their colleagues and should put pressure on those states that are not aggressively implementing Olmstead.  Examples of potential coalition goals include:

C  Seeking additional support for the immediate creation of additional community services;

C  Informing State legislators how best to prioritize the numerous recommendations included in state plans

C  Overseeing state progress implementing the HHS Systems Change grants described above.   A good source for information about state progress on these grants will be the upcoming report, mentioned above, by the Research Triangle Institute (RTI),  a comparative analysis of State proposals selected to receive grant money.  The report will probably be released by mid-October 2002.

C  Watching for states that restrict Olmstead implementation to only those projects funded under the federal grants.  Activities funded by these grants should just be one component of a range of administrative and legislative actions states take to move individuals into appropriate settings, and develop community services.

C  Reviewing and commenting on upcoming federal regulations that will impact access to community services and supports, including: 1) the Medicaid regulations governing HCBS waivers which are scheduled for review this year by CMS; and 2) the nursing home and intermediate care facility survey and certification regulations scheduled for issuance by CMS in November 2002.

For further information regarding state Olmstead implementation efforts and what advocates can do, please contact the National Association of Protection and Advocacy Systems at 202-408-9514 or see our website (www.napas.org under "disability rights information" "community integration").

***

Prepared by Elizabeth Priaulx, Senior Disability Legal Specialist, Training and Advocacy Support Center, NAPAS, 900 Second Street, NE, Suite #211, Washington, DC 20002.

The National Association of Protection and Advocacy Systems (NAPAS) is a membership organization for the Protection & Advocacy System.  The System is a Federally-mandated nationwide network of disability rights agencies that provide legal representation and advocacy services to people with disabilities.  The Training and Advocacy Support Center (TASC) provides training and technical assistance to P&As and is housed within NAPAS.  TASC is a federal interagency project of the Administration on Developmental Disabilities (ADD), the Center for Mental Health Services (CMHS), and the Rehabilitation Services Administration (RSA).

Endnotes


[1] Advocates interested in specific information on state efforts to implement the Olmstead decision are encouraged to go to the National Conference of State Legislators website at www.ncsl.org.  They have completed a two year Olmstead Progress Report as well as a survey of recent state initiatives to increase long-term care community supports. The Center for Health Care Strategies also plans to issue Implementing Community Integration: A Review of State Olmstead Plans, by Sara Rosenbaum, Joel Teitelbaum, and Alexandra Stewart to be available on line in October 2002 at www.chcs.org.

[2] This report is designed to be read in conjunction with an October 2002 NAPAS critique of recent federal agency efforts to implement the recommendations contained in Delivering On the Promise:  A Compilation of Individual Federal Agency Reports of Actions to Eliminate Barriers and Promote Community Integration.  This NAPAS paper is available at www.napas.org in the section on "disability rights information" under "community integration."

Compiled by the HHS Office of Disability, Aging and Long-Term Care Policy in May 2002.  It is available at http://aspe.hhs.gov/daltcp/reports/citarpt.htm.