1. Improving Community Living disAbility Services
Initiative to Form Individual Supports Budgets Based on an Assessment of Supports Needs
July 2015
John Agosta
Megan Villwock
Risa Rojas
Human Services Research Institute
7690 SW Mohawk Street
Tualatin, OR

2. Today’s Agenda Introductions What We Believe Project Work Plan
Improving Community Living disAbility Services
Today’s Agenda
Introductions
What We Believe
Vulnerable Persons Act and driving principles
Project intentions
Project Work Plan
General approach
15 Tasks by Phase
Timeline
Focus on Selected Tasks
Questions & Discussion

3. What We Believe Why are we doing this? One question to ask…
Improving Community Living disAbility Services
What We Believe
One question to ask…
Why are we doing this?

4. Improving Community Living disAbility Services
Why
How
What

5. Improving Community Living disAbility Services
What -- How -- Why
Manitoba Family Services
Departmental Vision
Manitobans with developmental disabilities are supported to achieve their fullest potential through inclusion in society, in economy and in the labor market.

6. VPA Philosophical Framework
Improving Community Living disAbility Services
VPA Philosophical Framework
Individuals with Disabilities should have the opportunity to:
Lead satisfying, productive lives in their communities.
Make their own decisions & direct their own lives, with support if necessary.
Take risks that they & their support network deem appropriate.
Use services that are available to all members of society with adaptation & support where possible.
maintain family bonds & develop relationships that are a natural part of life.
Supportive & protective services for individuals with disabilities should be individualized, community based & non-segregated.
When individuals are vulnerable & at risk of suffering harm to themselves or others, their rights & freedoms must be respected & the least restrictive form of support used.
VPA: The Vulnerable Persons Living with a Mental Disability Act. Philosophical Framework from An Overview of CLDS PowerPoint (updated July 2014).

7. Satisfying, productive lives Individualized Inclusive Support
Improving Community Living disAbility Services
Framing: Putting it Together
The “BIG Idea”
support to achieve their fullest potential through inclusion in society, in economy and in the labor market.
Participation
People achieve full potential
Satisfying, productive lives
Reasonable Risk
Individualized Inclusive Support
Least Restrictive
Secondary Themes
Satisfying and productive lives
Self direction
Reasonable risk
Participation
Individualized inclusive support
Least restrictive

8. Improving Community Living disAbility Services
Services & supports that people with developmental disabilities prefer
A Person-centered & sustainable system
Blending Together Principles Related to Service Delivery & System Management
Disciplined fiscal & management practices

9. Confidential Governor's Working Papers
Improving Community Living disAbility Services
Project Work Plan
The general approach
15 Tasks by two phases
Taskline
Review of selected tasks

10. Improving Community Living disAbility Services
General Approach
An assessment is used to assist with establishing individualized budgets. This also provides a way for policy makers to make fiscal choices that are fair & predictable, but also makes the best use of available money that’s consistent with driving system principles.
Allocating resources to people based on their assessed level of need. Each person receives what they need.
Establishing a best fit solution for most but taking care to accommodate individuals with extraordinary needs.

11. $ Improving Community Living disAbility Services
Little
Support Needed
A Lot
We want to move from a low correlation like THIS…
…to a high correlation like THIS

12. 1 2 Project Tasks 8 Tasks 7 Tasks 15 Tasks Total
Improving Community Living disABILITY Services
Project Tasks
CLDS expects that it will take 18 months to finish the service changes.
Phase 1 we’ll take a look at the current services for people with intellectual & other developmental disabilities and decide how they might be changed to make sure everybody’s needs are met.
Phase 1 2
Phase 2 we’ll build an individual budget system with help from the Supports Intensity Scale (SIS) & a matching provider rate schedule.
15 Tasks Total
8 Tasks
7 Tasks

13. Confidential Governor's Working Papers
Improving Community Living disABILITY Services
Phase 1
Phase 2
1 Convene inaugural meeting
2 Collect & analyze expenditure data
3 Review service definitions
4 Identify a statistically valid SIS Sample group
5 Add Supplemental Questions to SIS interview
6 Identification, review, & analysis of SIS info
7 Develop a process & strategy for stakeholder engagement
8 Plan next steps
9 Analyze support needs & expenditures for level assignment
10 Establish budget guidelines by level
11 Conduct validation study to validate budget levels
12 Consider adjustments to individual supports planning
13 Consider infrastructure adjustments
14 Provide ongoing technical assistance
15 Final report with recommendations & implementation plan

14. Improving Community Living disABILITY Services

15. Confidential Governor's Working Papers
Improving Community Living disABILITY Services
Selected Task Updates
Task 6: SIS Data Collection
Task 5: Supplemental Questions and the SIS interview
Task 3: Review service definitions
Task 7: Communications

16. Confidential Governor's Working Papers
Improving Community Living disAbility Services
Selected Project Tasks: Brief Update
Task 6: Identification, review & analysis of SIS information. 2,043 individuals were identified for the sample. Roughly 1,312 interviews are completed.
Task 5: Add Supplemental Questions to SIS interview. SIS interviewers received supplemental question training &HSRI worked with CLDS to develop a verification process to identify people with extraordinary support needs.
Task 3: Review service definitions. Service definitions were reviewed & a report was prepared for CLDS that will assist in altering service definitions to more accurately capture system-wide goals. CLDS formed a work group that will begin reviewing service definitions.
Task 2: Task 7: Develop a process & strategy for stakeholder engagement. CLDS worked with HSRI to develop a plan for engaging with stakeholders.

17. Task 6: Sample Status Sample Status (7/1/15)
Improving Community Living disABILITY Services
Task 6: Sample Status
Sample Status (7/1/15)
Stratifier
Population
Percent of Population
Target Sample
Total SIS Assessments
% Complete
Group Home
1,360
23%
422
409
96.9%
Foster Home
774
13%
342
256
74.9%
Independent
962
17%
375
202
53.9%
Family
1,847
32%
462
281
60.8%
Under 18
136 2%
109 44
40.4%
Other
729
333
120
36.0%
Total
5,808
100%
2,043
1,312
64.2%

18. Supports Intensity Scale
Improving Community Living disAbility Services
Supports Intensity Scale
Administration: Interview the person and others who know the person. Requires solid interviewing skills
Measures general support needs of an individual producing a number of scores
Includes basic support need areas like:
A. Home Living Activities,
B. Community Living Activities,
C. Lifelong Learning Activities
D. Employment Activities
E. Health and Safety Activities
F. Social Activities
SIS ABE – refers to the sum of the scores for these 3 areas that have been found useful in helping resource allocation
Identifies Medical and Behavior problems which are also significant cost predictors

19. What the SIS Measures Individual Being Assessed:
Improving Community Living disAbility Services
What the SIS Measures
SIS
measures
the difference
Individual Being Assessed:
Expectations
Responsibilities
Involvement in the activity
Standard of a Typical Adult:
Expectations
Responsibilities
Involvement in the activity
Type of Support
Frequency of Support
Daily Support Time

20. Sample Status by Region (7/1/15)
Improving Community Living disABILITY Services
Sample Status by Region
Sample Status by Region (7/1/15)
Region
Target Sample
Total Assessments
% Complete
Central
255
202
79.2%
Eastman
170
140
82.4%
Interlake
173
136
78.6%
Northern 66 50
75.8%
Parkland 73 52
71.2%
Westman
268
221
82.5%
Winnipeg
1038
511
49.3%
Total
2,043
1,312
64.2%

21. Confidential Governor's Working Papers
Forming Individualized Supports Budgets
Comparison Across Jurisdictions
Number of Individuals
Supports Need Index
Sum of Part A, B, and E
Medical Need Score
Behavioral Need Score
SIS Norm
1,306
100.00
30.00
3.23
4.99
Manitoba
1,312
91.92
25.03
1.35
3.34
Alberta
5,061
91.77
24.81
1.86
3.73
Tennessee *
5,765
102.67
30.36
1.45
2.87
Virginia **
1,275
102.82
30.16
1.96
2.64
Oregon *
5,119
106.33
31.62
1.99
5.06
New Mexico *
3,218
106.31
31.75
3.13
4.82
Utah
4,114
102.15
30.09
2.22
4.09
Rhode Island
3,007
101.75
29.72
2.02
4.19
Kentucky *
3,476
99.76
28.93
1.92
4.28
Georgia
10,574
99.40
28.62
1.39
2.69
Maine *
2,324
98.71
28.35
2.04
4.64
Louisiana *
4,091
98.23
29.95
3.33
3.10
Colorado
6,849
97.49
27.91
2.99
5.55
*State reporting a portion of their HCBS population
* States with partial population for HCBS population **Weighted for entire HCBS population.

22. Improving Community Living disABILITY Services
Supports Needs Index Distribution
(July 2015)
Sum ABE Distribution July 2015

23. Task 5: Supplemental Questions
Improving Community Living disABILITY Services
Task 5: Supplemental Questions
So far we’ve:
Provided CLDS a memorandum explaining options associated with verification of SQ responses.
Are tracking the number of people triggering the SQs and will need verification. Next we need to identify individuals who trigger the SQs and require verification.

24. Improving Community Living disABILITY Services
Seven Support Levels
Low Support Needs High 1 2 4 5
Modest support needs & some behavioral support needs 3
Significant Behavioral support need 7
Significant Medical support need 6

25. Seven Assessment Level Descriptions
Improving Community Living disABILITY Services
Seven Assessment Level Descriptions 1
Adults in this level have low support need, including some to no support need for medical and behavioral challenges. They can manage many aspects of their lives independently or with little assistance. 2
Individuals in this level need more support than those in Level 1, but their support needs are minimal to modest in a number of life areas. Adults in this level have moderate support needs and little to no support need for medical and behavioral challenges. 3
Adults in this level have low to moderate support needs as in Levels 1 and 2. They also have an increased, though not extraordinary, support need due to behavioral challenges. 4
Adults in this level have moderate to high support needs. They need help with life activities on a daily basis. They may have behavioral support needs, but these needs are not extraordinary. 5
Adults in this level have high to maximum support needs. They need help with life activities typically requiring hands on support and/or oversight throughout the day. They may have behavioral support needs, but these needs are not extraordinary. 6
Adults in this level have extraordinary need for medical support Individuals in this level may have behavioral needs, but these needs are not extraordinary. 7
All adults in this level have extraordinary behavioral challenges, regardless of their support need to complete daily activities or for medical conditions. Adults in this level need greatly enhanced supports due to their behavioral challenges.

26. Developing Levels & Budgets
Improving Community Living disAbility Services
Developing Levels & Budgets
Sample
Assess & Levels
Services & Rates
Residence
Service Packages
Validate
Design a random stratified sample for each targeted subpopulation.
Assess needs using the Supports Intensity Scale (SIS) & assign individuals to Levels.
Consider where people live.
Settle on the service array & reimbursement rates.

27. Developing Levels and Budgets
Improving Community Living disAbility Services
Developing Levels and Budgets
Build service packages by Level based on common supports needs and living situation.
Base budgets include in home, residential, employment, or day services.
Some services are managed outside the base, including professional or non-recurring supports.
Utilization of services by level is anticipated.
Service packages are priced by level to establish individualized budgets.
Individuals are not tied to anticipated service packages. Resource allocation does not limit person-centered choices, but sets a budgetary limit.
Systematically validate the service packages & make revisions as needed.

28. Level Based Individualized Budgets
Improving Community Living disAbility Services
Level Based Individualized Budgets
Budgets vary according to levels that group people from least to highest support needs.
Each level represents a certain amount of money for services.
In some cases other services can be added on to get a higher personal budget allocation.
Processes are implemented to address exceptional needs.

29. $ Seven Level Model Forming Individualized Supports Budgets
Potential “Add On” Services $
Budget Allocation
Base Budgets Per Category
Low Support Needs High

30. Examples of Base and Add-on Services
Improving Community Living disAbility Services
Examples of Base and Add-on Services
Base Budget Services
Add-On Budget Services
Residential Supports
Respite
Day Supports fees
Supported Employment/Follow-up
Personal supports
Special rate services
Transportation
Crisis Services
Specialized Consultation Services
Vehicle Modifications
Home Modifications

31. Task 3: Service Definition Review
Improving Community Living disABILITY Services
Task 3: Service Definition Review
So far we’ve:
We’ve collected materials from CLDS & considered identified service definitions against the five criteria.
We’re in the process of reaching conclusions to inform the Service Definition Committee. Preliminary findings suggest variance across providers regarding how some definitions may be interpreted and reimbursed.

32. Five Criteria Applied to Seven Service Types
Improving Community Living disABILITY Services
Five Criteria Applied to Seven Service Types
Have embedded policy intentions.
Concisely state the behavior expected of service providers delivering the service, including the qualification of those who may deliver the service.
Indicate the unit by which the service will be delivered.
Indicate the rate of reimbursement per unit of services and any limitations on how often a service can be assessed.
Are applied consistently throughout a service system.
Residential Services In the Company of Friends Day Services Crisis Intervention
Respite Services Clinical Services
Transportation

33. Task 2: Expenditure Data
Improving Community Living disABILITY Services
Task 2: Expenditure Data
So far we’ve:
Collected information from CLDS by person, by provider, and by region.
Reviewed service contracts for individual requests for services & comprehensive provider contracts.
Selected agencies for closer review.

34. Task 2: Expenditure Data
Improving Community Living disABILITY Services
Task 2: Expenditure Data
Region
Northern
$6,195,406 2%
Parkland
$11,440,648 4%
Interlake
$21,007,747 7%
Eastman
$23,926,028 8%
Central
$24,683,615
Westman
$33,610,464
11%
Winnipeg
$190,592,118
61%
Grand Total
$311,456,026
100%
Note: An additional $13,910,727 is allocated to Directorate SDS

35. Expenditures and Average Costs Per Person (FY 2014)
Improving Community Living disABILITY Services
Expenditures and Average Costs Per Person (FY 2014)
Region
Total 2014 Expenditures
# Served
Average per Person
Central
$23,117,060
449
$51,486
Eastman
$22,585,474
429
$52,647
Interlake
$19,715,073
318
$61,997
Northern
$5,947,806
100
$59,478
Parkland
$10,598,257
185
$57,288
Westman
$31,594,053
446
$70,839
Winnipeg
$179,625,505
2,529
$71,026
Grand Total
$293,183,228
4,456
$65,795
Note: Findings include only for individuals who received services for the full fiscal year.

36. Running into some issues…
Improving Community Living disABILITY Services
Running into some issues…
We suspect that there is a lot of variance across the Province regarding how providers are reimbursed.
The variance could include differences in:
Service unit standards for the same service,
What is paid per unit for a service, or
What is paid for the same service for the same person.
We need to discuss how we might get a better understanding of these issues in advance of thinking about “service packages” and supports budgets.

37. $ For example… Improving Community Living disABILITY Services
Varying rates for the same service. $
Service A 
Service B
Service C
Service D

38. A Sneak Preview… Improving Community Living disABILITY Services
Correlation strength (Pearson’s R) = .488 – moderate correlation
Variance explained (R2) = .23

39. Person centered planning is essential
Forming Individualized Supports Budgets
Person centered planning is essential
SIS results may be used to guide service planning but not necessarily to drive planning.
The SIS interview may push participants to discuss topics they might not ordinarily talk about.
Valuable personal or habilitation goals may lay outside the bounds of the SIS interview.
Use conversational & other means to develop person-centered plans.

40. The Way Things Are… Forming Individualized Supports Budgets
Services are provided to people living in isolated households.
Dependency on services
Isolation
Fail to build culture & capacity to increase opportunity for mutual support & use community resources

41. The Way Forward… Forming Individualized Supports Budgets
Public services work together to use community assets with mutual support.
Network
Rely on multiple sources of support
Kinship
Establish culture & capacity to increase opportunity for mutual support & use community resources
Purchasing alliance

42. An Overall View… Forming Individualized Supports Budgets
Public resources available.
Lives of people with IDD & their families
Community assets & individual efforts
People with IDD & their support needs
Harkins, Green, Jacobson & Agosta 2011

43. Task 7: Communications So far we’ve:
Improving Community Living disABILITY Services
Task 7: Communications
So far we’ve:
Submitted a plan for stakeholder engagement.
Prepared talking points to illustrate how this project responds to concerns for the system.
Considered moving project resources to provide CLDS more assistance.
“Demonstrate that your efforts are transparent & that through these actions, you care about what happens to people.”

44. Confidential Governor's Working Papers
Improving Community Living disABILITY Services
Task 7: Develop Stakeholder Process & Strategy
Five Communications Tasks
1. Develop & frame CLDS policy goals & driving thematic principles.
2. Learn stakeholder discourse, perceptions & media coverage.
3. Disseminate materials online & in print for public & internal use.
4. Devise & conduct means to engage stakeholders.
5. Establish communities of practice to support & maintain mutual learning.
Potential Means

45. Supporting Policies, Rules & Regulations and Communication
Forming Individualized Supports Budgets
Looking Things Over
Access
Getting a Budget
Service Planning
Service Delivery
Quality Monitoring
Eligibility
Understanding the Process
SIS Interview
Share SIS Results
Set Level Assignment
Set Supports Budget
Inform People of Their Level & Budget
The Budget & Service Packages
Personal Preferences
Exceptions
Creating a Service Plan
Arranging for Service Delivery Service Delivery
Paying for Services
Voicing Complaints
Monitoring Making Changes
Supporting Policies, Rules & Regulations and Communication

46. Next Steps Project Name Verification of SQs Service Definitions
Improving Community Living disABILITY Services
Next Steps
Project Name
Verification of SQs
Service Definitions
Expenditures and PCG Visit
Analyses by Level
Communications
Person Centered Planning