1. DOORS: Individual Budgets Based on Individual Needs Jon Fortune, EdD Wyoming Department of Health Developmental Disabilities Division IASSID World Conference Montpellier, France June 15, 2004

2. The ETERNAL QUESTION: How do we deliver what we have to the people who need it most ?

3. Before

4. After (2003 Adults)

5. Introduction n DOORS Model n Stepwise regression n Individual budget for each person served for use by the local team n Uses regular Medicaid HCBS DD waiver n Funding related to characteristics of person n Wyoming financial architecture

6. Overview - History & Results n Began in July 1998 for adults and in January 1999 for children n No hearings to date n Some requests for State Level of Care Review n Focus on the needs of the person served n Very stable for financial planning

7. Agenda n What did we tell the families and people served? n Campbell & Heal, 1995 AJMR n Rhoades & Altman, 2001 MR n ICAP items and other data pieces n DOORS - Gary Smith & Bob Clabby n Model can be done on a spreadsheet

9. n Model - “A tentative description of a system or theory that accounts for all of its known properties.” (American Heritage Dictionary, 1985) - we are referring to a mathematical formula which attempts to describe the relationship between independent predictors and dependent measures of interest like the budget for reimbursement

10. Assumptions: 1. Individual People have needs, not providers, agencies, or groups. 2. Individuals with greater needs should have access to more resources; those with lesser needs should get less. 3. No two people have the same needs, supports and priorities. The word “Individual” must mean something.

11. Assumptions: (cont.) 4. Individuals and their teams know best what services are most important for that person, not the State. 5. People should choose providers, not the other way around. 6. It is possible to make it happen.

12. Overview - Strategy n Fairness, equitability, explicability n Match resources and individual needs n Ability to handle special cases n In a time of limited resources - focus on those with greatest demonstrated need

13. Overview - Strategy n Find predictors that we can use for constructing a statistical model, or formula, to generate predicted budget for each eligible person on the waiver

14. What factors explain variance? (Remember, your results at home should vary!) n Autism, Deafness, Mental Illness, level of MR, health limitations, psychotropic meds, lives with family, ICAP Broad Independence, ICAP Gen Maladaptive, lives independently, SE, etc.

15. Robustness n The techniques are often powerful enough to be able to overcome minor error and work well

16. All the predictors work together as a team, like the attacking army on a chessboard

18. Database Invaluable n Information about people served and service use is needed

19. Regression - Comments, Conditions & Caveats: n It is best to have “orthogonal” regressors; ones not correlated with each other, not collinear n An important regressor might have a large probability value (i.e. may not be statistically significant) if the sample is small, if the regressor measures a narrow range with large measurement errors, or a closely related regressor is included

20. Limitations n There are some n Hold some dollars for exceptional cases n There is a budget n This surprises no one

21. Does not ensure enough money n Can provide a fair way to distribute the money available n Does offer a way for money to follow the person served n Provides the local team an understandable budget that they can use in pursuit of choices & preferences

22. Wyoming Financial Architecture n 1. DOORS to match dollars to people n 2. Clear assignment of authority to make decisions about services to local team that supports each person n 3. Authority for individuals to select their own service coordinators

23. Wyoming Financial Architecture n 4. Resolute adherence to principle that individuals and families have free choice of service providers n 5. Policies that encourage – rather than impede – new providers stepping forward to offer supports to individuals

24. The Four “P”s 1. PERSONAL * Individual, not group * Real information about each person * Model comes from individual characteristics, not the other way

25. The Four “P”s 2. PORTABLE * Person has funding, not provider * Person chooses provider * Funding moves with the person * No “guaranteed clients”

26. The Four “P”s 3. PRIORITIZED * Person & Team set priorities * People with greatest need get most

27. The Four “P”s 4. PREDICTABLE Both the Individual and System know & plan within their limits

29. Special Thanks to Professor Laird Heal Bradley K. Hill (ICAP) Wayne Johnson Edward M. Campbell, Ph.D. Don Severance

30. “DOORS” Contact Information Jon Fortune, Ed.D. Jfortu@state.wy.us DDD Wyoming Web Site http://ddd.state.wy.us