POLICY, GOALS AND ISSUES IN STATE I/DD SYSTEMS ASAN – Autism Leadership Training August 17, 2015 Mary Lee Fay National Association of State Directors of Developmental Disabilities Services

agenda Impact of Advocacy - History Where do we want to go Impact of Medicaid and new Rules Other challenges to supports Advocacy - Today

Know the History The asylum model 1800s

The Impact of Public Policy The Right to Education in Pennsylvania Medicaid Home & Community Services 1981 Civil Rights if Institutionalized Persons Act 1980 ADA 1990 Olmstead Decision 1999 Cecil George Painea achieved the first recorded cure with penicillin of igonococca infection in infants The asylum model 1800s

People with Disabilities Make Change Americans with Disabilities Act Olmstead Litigation

Self-Advocates and Families Must Engage, Lead, & Drive Change

Slides by the RISP and FISP Projects at the U of MN's RTC on Community Living

Movements Shaping DD Supports 1950s Mom Parent-----Family Movement 1970s Self-Advocacy and Independent Living Movements (Not about me, without me) 2000s Siblings Movement 1970s Rehab Act: 504 Plans 1975s Education for All Children 1990s IDEA and ADA 1960s Medicaid and Medicare Established 1980s Medicaid Waiver (Community Supports) 2010s Affordable Care Act Community Family Person with Disability 1990 and 2000’s Olmstead Community and Society

What we know about current realities for pressures for change? 9 Expectations, Values, Culture Evidence Based Practices Policies and Budget Demand for Services Community Family Social and Medical Services Person with Disability Language and Words

Supports should enhance real lives

Current Support System

Real People, Real Lives with Integrated Supports

How do we get there Trajectory toward a good life Trajectory towards things you don’t want

What is a trajectory? Trajectory toward a good life Trajectory towards things you don’t want Friends, family, job, fun things to do, independence, your own place, happiness Vision of What I Don’t Want

Katie’s Good Life Trajectory Trajectory toward a good life Trajectory towards things you don’t want VISION FOR GOOD LIFE Help other people with disabilities My own place Get married Get my journalism degree Vision of What I Don’t Want To be labelled To be unhappy Started college at State Fair Special ed classes Moved in my own place ASAN Leadership

Exercise What is a good life trajectory

We all use Supports

i-pad/smart phone apps, remote monitoring, cognitive accessibility, adaptive equipment person or family resources, abilities, strengths, characteristic s SHS services, Special Ed, Medicaid, section 8, Food Stamps, Vocational Rehab (VR)

Relationships Who do you have in your life to help you? Family Friends Close personal relationships (like your neighbor, boss, pastor coworkers, etc) family, friends, neighbors, co- workers, community members, church members

Personal Strengths & Assets What do you have that will help you? Personality traits Skills or training that you have Belongings that own or things you have access to person or family resources, abilities, strengths, characteristics

Technology How can technology help you be more independent? Smartphones Assistive technology Internet and computers i- pad/smar t phone apps, remote monitorin g, cognitive accessibi lity, adaptive equipme nt i-pad/smart phone apps, remote monitoring, cognitive accessibility, adaptive equipment

Community- Based Businesses, places, and things anyone can access where you live: School Library Park Police station Hospital Church Grocery Store school, businesses, church/faith based, public transportation, parks and recreation Library, church, Community collage Coffee shops

Eligibility Specific Things you have to have a diagnosis, certain income, or other qualification (like age, gender, or race) for Food stamps Housing Voucher DD Services Medicaid Medicare SHS services, Special Ed, Medicaid, section 8, Food Stamps, Vocational Rehab (VR)

exercise Pick 2 areas that are not eligibility services that support you to get up in the morning

Marilyn’s Integrated Supports Smartphone, laptop, Kindle Fire, Facebook Wal-mart, Schmitty’s, YMCA, Southern Heights Christian Church Nephew Burt, my brother Don, Rachel, Katie, Patty, Phyllis, Gary SSDI, Medicaid, Food stamps Outgoing, helpful, good heart, Partners in Policymaking, Project STIR, Rents her own apartment MARILYN’S INTEGRATE D SUPPORTS

ELIGIBILITY SERVICES MEDICID FUND SERVICES

Without Medicaid, There Would Be No Services NASDDDS National Association of State Directors of Developmental Disabilities Service

Medicaid Long Term Supports and Service (LTSS) Spending $140 billion in FFY 2012 – institutional and community Home and community-based services (HCBS) % or almost $75,000,000, % for people with developmental disabilities 39 % for older people or people with physical disabilities 35 % for people with serious mental illness or serious emotional disturbance. Steve Eiken:Truven Health Analytics

Who Are We Serving? 36% Co-occurring DD/MI 11% Autism (4% in WY to 19% in NJ) 15% Cerebral Palsy 31% Seizures/neurological conditions 5% TBI Behavioral disorders Communication disorders NCI Consumer Survey

89% of People I/DD are Supported by Family 30

An Overview CMS RULES FOR HOME AND COMMUNITY BASED SERVICES

The "big deal” items….. HCB Settings Character What is NOT community What is likely not community What is community Person-centered planning 32 NASDDDS 4/17/14

Before we define HCB Settings character.. Settings that are NOT Home and Community-based: Nursing facility Institution for mental diseases (IMD) Intermediate care facility for individuals with intellectual disabilities (ICF/IID) Hospital 33 NASDDDS 4/17/14

Settings that we do not think would Be Home And Community -based Settings in a hospital, nursing home or institution Settings on grounds of, or next to, a hospital, nursing home or institution (even if it is a house, if it on the campus of an institution it is NOT in the community. Or a separate hallway in a nursing home) Settings with that keep the people away from the community – they “isolate” the person 34 NASDDDS 4/17/14

But…. States may ask the Federal Government for permission to use these settings IF they can show that people REALLY are living in the community (they leave and go to work, friends and family come over to see them, they go shopping in town….) This is called “Heightened Scrutiny” 35 NASDDDS 4/17/14

SO – What does “settings” mean in the Rule States have to show that where people LIVE and WORK and spend their DAY are in the community Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services 36 NASDDDS 4/17/14

MORE from the Rules The person CHOOSES where they live and work and spend the day The setting options are written down in a person-centered service plan and are based on the individual’s needs and, preferences. 37 NASDDDS 4/17/14

The Rule ALSO Says people… A person has the right of privacy, dignity, respect They have independence in making life choices Facilitates individual choice regarding services and supports, and who provides them Be aware this is not just residential…the rule applies to ALL settings including day programs… 38 NASDDDS 4/17/14

There MUST be Person-centered planning The person-centered planning process is driven by the individual Includes people chosen by the individual Provides necessary information and support to the individual to ensure that the individual directs the process to the maximum extent possible Is timely and occurs at times/locations of convenience to the individual Reflects cultural considerations/uses plain language Includes strategies for solving disagreement Offers choices to the individual regarding services and supports the individual receives and from whom 39 NASDDDS 4/17/14

Person-centered planning says what is important to the person and what is important for the person “What do people know and like about me” May include what control the person wants to have Hiring staff, deciding about the budget Opportunities to seek employment and work in the community 40 NASDDDS 4/17/14

Person-centered planning Written plan reflects – Setting is chosen by the individual and is integrated in, and supports full access to the greater community Opportunities to seek employment and work in competitive integrated settings Opportunity to engage in community life, control personal resources, and receive services in the community to the same degree of access as individuals not receiving Medicaid HCBS 41 NASDDDS 4/17/14

CHALLENGES

DEMOGRAPHIC CLIMATE CHANGE

Baby-Boom Generation National Institute on Aging 44

Every day 10,000 Baby Boomers qualify for Social Security Workers per Social Security Beneficiary 45

Shortages of Care Givers as America Ages A labor shortage is worsening in one of the nation's fastest-growing occupations—taking care of the elderly and disabled-just as baby boomers head into old age. Wall Street Journal April Larson, Edelstein,

Pressures on Funding 47

We are Confronted with Reality The Waiting List Growth in public funding will slow Workforce will not keep pace with demand People Waiting For Services Residential Capacity Growth Needed 76,677 RISP , % 48

WE CAN’T AFFORD TO EXPAND SERVICES THAT REQUIRE 24 HOUR CARE

Remember this!

Focusing on Relationship Based Living Options Living with siblings Living with other relatives Living with Friends Living with a partner Supported Living – supports provided in the person’s own home Shared Living – the person matched to live with another 51

Focusing on Employment Get out of poverty More independence Make Friends Make a contribution to the community Positive image and valued role within the family and community Opportunities for learning and expanding relationships 52

Advocacy and Employment How to make changes in Employment Outcomes

Employment and Day Supports IDD Agencies ICI National Survey of State IDD Agencies 2012

Growth in non-work CRP Survey

People Want to Work No paid job 85% Paid job 15% Does not want job 54% Wants job 46% No job goal in the plan 72% Job goal 28% NCI Data Brief NCI Data 85,560 working 56

WHAT WE DON’T WANT living a service life What will you do to change Employment Outcomes WHAT WE WANT People are working and living in community Social Networks Support from family and friends Developing skills Dreaming Big

Mary Lee Fay Executive Director National Association of State Directors of Developmental Disabilities Services 301 N. Fairfax St., #101 Alexandria, VA NASDDDS National Association of State Directors of Developmental Disabilities Services