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

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 2Gold

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 3Gold

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 4Gold

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 5Gold

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 6Gold

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) 7Gold

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 8Gold

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 9Gold

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 10Gold

11. Utilization: 2008-2010 11Gold

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

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 13Gold

14. Fee-for-Services vs. Managed Care Less than 1 percent in fee-for-service programs 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 14Gold

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 15Gold

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 16Gold

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 17Gold

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 18Gold

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 19Gold

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 20Gold

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/inde x.html Elizabeth Jones, Ph.D., CDS Specialist 512.438.4855 elizabeth.jones@dads.state.tx.us 21Gold

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. 22Gold