Missouri's Olmstead Implementation

Activity No. 1:  Identify the current number of and current level of funding for home- and community-based services and consumer-directed care programs for individuals with disabilities in the state of Missouri.

Department of Elementary and Secondary Education, Division of Vocational Rehabilitation
Department of Mental Health
Department of Mental Health, Division of Alcohol and Drug Abuse
Department of Mental Health, Comprehensive Psychiatric Services
Department of Mental Health, Division of Mental Retardation/Developmental Disabilities
Department of Health, Bureau of Special Health Care Needs, Adult Head Injury Program
Department of Social Services, Division of Aging
Department of Social Services, Division of Medical Services

Background Information

This first activity was designed to identify the current number of and current level of funding for home and community-based services and consumer-directed care programs for individuals with disabilities in Missouri.

Each state department (or program division) had its own listing of the current number and current level of funding for home and community-based services and consumer-directed care programs for individuals with disabilities in Missouri.  This section will describe these numbers separately by appropriate state program. 

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Department of Elementary and Secondary Education -
Division of Vocational Rehabilitation

Personal Assistance Services (PAS) Programs

The Division of Vocational Rehabilitation operates three Consumer-Directed Personal Assistance Services (CD-PAS) Programs for the benefit of consumers who require personal care services.  The three programs are Non-Medicaid Eligible, Medicaid State Plan and Independent Living Waiver.  These statewide programs are administered locally by twenty-one Centers for Independent Living.

The Non-Medicaid Eligible (NME) Program has been in existence since 1985. This program enables consumers with physical disabilities who are "employed or ready for employment" to maintain or seek such employment by utilizing personal care services through this program.  The NME Program is funded through state general revenue appropriation.  This program served as the model for the development of the Medicaid State Plan (MSP) and the Independent Living Waiver (ILW) Programs.

The Medicaid State Plan (MSP) Program has been in existence since 1993.  This program targets the Medicaid-eligible population with physical disabilities.  Eligible consumers may access personal care services up to a monthly maximum of $2,295.  The MSP Program is funded through a combination of Federal and State funds.

The Independent Living Waiver (ILW) Program started January 1, 2000.  This program targets the Medicaid-eligible population with physical disabilities or cognitive disabilities who require Personal Care services above the MSP maximum of $2,295 or Specialized Medical Equipment and Supplies or Environmental Accessibility Adaptations or Case Management. (See Table 1.)

Table 1. Number of Consumers and Level of Funding - Division of Vocational Rehabilitation

Note:  Data as of 10/31/00
*Does not include HB1111 Funding

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Department of Mental Health

The Department of Mental Health consists of four divisions:  Comprehensive Psychiatric Services, Alcohol and Drug Abuse, Mental Retardation and Development Disabilities and the Office of the Director.  The total operating budget for the FY 2001 is $682,823,496.  Of this amount $630 million represents core funding and $52.8 million is appropriated as new funding.  Comprehensive Psychiatric Services received approximately 45% of the budget (or $310,922,739) and the Division of Mental Retardation/Develop-mental Disabilities 39% (or $266,344,377).  Figure 1 presents the operating budget for FY 2001.

Department of Mental Health - Division of Alcohol and Drug Abuse

The Division of Alcohol and Drug Abuse offers prevention and treatment services  through a network of community contracted providers.  The only services that take place in Department of Mental Health inpatient facilities are 96-hour involuntary commitments.  The Division routinely monitors the community-based providers and their treatment staff, who must meet state certification standards.  A methodology for priority distribution of new resources, based on both population and risk factor measures, has recently been developed.

The Division's total budget for FY 2001 is $77,017,172.  Of the budgeted amount, funding for treatment services is 74.3 percent; prevention 14.7 percent; Substance Abuse Traffic Offender Program 4.6 percent; compulsive gambling 0.6 percent; and administration 5.9 percent.  (See Table 2.)

Table 2. Funding Distribution by Service:  ADA

The sources of funding were predominantly federal (48.1%) and general revenue (40.9%).  (See Table 3.)

Table 3. Sources of Funding: ADA

Approximately 68.2% of Missouri residents served by the Division of Alcohol and Drug Abuse were served by the outpatient rehabilitation program.  (See Table 4.)

Table 4. Number of Consumers Served: ADA

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Department of Mental Health - Comprehensive Psychiatric Services

The Division of Comprehensive Psychiatric Services (CPS) is charged with the delivery of services to persons with mental illness throughout the state of Missouri.

The Division divides Missouri into 25 service areas.  Each service area has a contracted Community Mental Health Center designated as the division's administrative agent.  These administrative agents serve as the primary entry and exit point for state mental health services and are responsible for the assessment and services to persons in their assigned areas and for providing follow-up services for persons released from state-operated inpatient services.  Children and youth are provided services in much the same way through contracts with administrative agents and state-operated children's hospitals.

Supported community living programs are provided for persons with mental illness who do not have a place to live or who need more structured services while in the community.  These programs range from nursing homes to apartments and other standard living accommodations in the community.  Persons in these programs receive support through case management and community psychiatric rehabilitation programs provided by administrative agents and affiliated providers.

Approximately 75.7% of the consumers served by Comprehensive Psychiatric Services (38,269) were served by the general outpatient category.  An additional 22.9% of the consumers (11,570) were served by the Community Psychiatric Rehabilitation program (both adults and children).  An additional 745 consumers were served in the Families First program (1.5%).  (See Table 5.)

Table 5. Non-Institution Community Support:  Comprehensive Psychiatric Services
Comprehensive Psychiatric Services

* Numbers duplicated between programs

The age distributions can be found on Table 6.  Most of those served (94.3%) were between 18 and 64 years of age.

Table 6. Non-Institutional Community-Based Residential Settings
Comprehensive Psychiatric Services

A further analysis by the type of community living arrangement found that the majority of those in supportive community living arrangements resided in Residential Care Facilities (77.5%).  Table 7 presents these findings.

Table 7. Supportive Community Living Arrangements (as of June 1, 2000)
Comprehensive Psychiatric Services

The Program Review for the Department of Mental Health listed the proposed funding for specific Comprehensive Psychiatric Services community-based programs for FY 01. Table 8 lists these proposed expenditures by program.  The major expenditures are projected for the Adult Community Supports program ($80,709,750 or 38.7%) and the Community Psychiatric Rehabilitation Program ($59,100,000 or 28.3%).

Table 8:  Expenditures by Program   FY'01 Projections:
Comprehensive Psychiatric Services

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Department of Mental Health - Division of Mental Retardation/
Developmental Disabilities

The Division of Mental Retardation and Developmental Disabilities MRDD) has the responsibility of insuring that mental retardation and developmental disabilities prevention, evaluation, care, habilitation, and rehabilitation services are accessible, wherever possible.  The Division serves persons who have been diagnosed with mental retardation or some other developmental disability.  A qualifying individual's mental retardation must have occurred before the age of 18, while any other developmental disability must have occurred before age 22.  All conditions must be expected to continue indefinitely and result in substantial functional limitations.  The Division's primary mission is to help improve the lives of persons with developmental disabilities through programs and services which enable those persons to live independently and productively, given their individual needs and capabilities.

The Division is moving forward in its expansion of consumer and family directed supports.  This will allow individuals with developmental disabilities to receive supports in the most integrated setting - with their families or in their own homes, take a leading role in planning and directing their services and supports, and participate fully in all aspects of home, school, work, and community life.

The Division operates habilitation centers and regional centers that provide or purchase specialized services.  Eleven regional centers form the framework for the system, backed by six habilitation centers, which provide residential care and habilitation services for persons with more severe disabilities.

The regional centers, based in eleven principal sites and supported by numerous satellite locations, are the primary points of entry into the system.  The regional centers provide assessment and case management services, which include coordination of each consumer's person-centered plan.  Each center serves from three to fifteen counties.

A total of  25,951 individuals with mental retardation or developmental disabilities are projected to be served during FY'2001 by the Division of Mental Retardation/Developmental Disabilities by Regional Centers.  Almost half of these individuals (46.6% or 12,091) will be under the age of 21 years.  The remainder (13,860) are 21 years of age or older.  The majority of those served are male (15,327 or 59.1%).  Females represent 40.9% of those served (10,624).  The racial distributions show that the majority (77.4% or 20,086) are Caucasians. There were 4,469 (17.2%) African Americans and 1,396 (5.4%) "other" category.  See Figure 2.

The appropriations for these community programs is $123,040,928.  The majority of the funding is found in the Community Residential Program ($68,534,872 = 55.7%).  An additional 16.4% of the funds are designated for the Consumer & Family Directed Support Program ($20,147,071). See Table 9.

Table 9. Community Programs Appropriation: Division of Mental Retardation/Developmental Disabilities

For persons maintained in their natural home environment, the FY 2001 budget projects that an additional 11,758 persons will be served.  Most of these will be in the in-home support program (5,461 or 46.4%).  Approximately 28.5% of the consumers were projected to be served in the Early Intervention Program (1,440 children).  See Figure 3.

Consumer Counts are duplicated between categories

The appropriations for these programs can be found on Table 10. The in-home support program represented 34.1% of the total ($11,398,840). The early intervention program is 28.7% of the budget ($9,593,238).

Table 10. Appropriations

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Department of Health - Bureau of Special Health Care Needs
Adult Head Injury Program

In the Adult Head Injury Program, service coordination is available statewide, free of charge, to survivors of traumatic brain injury who have reached their 21^st birthday, regardless of financial status.  Individuals may contact a service coordinator, or may be referred, with their permission, by physicians, family, friends, rehabilitation centers, service agencies, and support organizations.

Rehabilitation services listed below are available to individuals who are eligible for the program, whose income is 185% of Federal Poverty Guidelines or lower.  These services may be provided to eligible clients when necessary to facilitate the client's achievement of a long term goal as indicated in the Program Service Plan.  The provision of rehabilitation services is subject to availability of funds which are appropriated annually.  All rehabilitation services must be prior authorized.  The Department of Health is payer of last resort.  The Head Injury Program Service Coordinator will assist the client to apply for any other payment resources before submitting requests for use of program funds. 

• Neuropsychological Evaluation and Consultation
• Behavioral Assessment and Consultation
• Adjustment Counseling
• Comprehensive Day Program
• Transitional Home and Community Support
• Pre-Vocational/Pre-Employment Training
• Supported Employment/Follow Along
• Special Instruction
• Physical Therapy Evaluation/Treatment
• Occupational Therapy Evaluation/Treatment
• Speech Therapy Evaluation/Treatment
• Recreation Activities
• Respite Care
• Transportation

The number of individuals served during the past few years has increased from 243 in 1997 to 535 in 1999 and a projected 540 in 2000.  (See Figure 4.)

Some of the demographics about those served are found on Table 11. Approximately 80% of those served are Caucasian.

Table 11. Racial and Ethnic Background - Adult Head Injury Program

Most program participants were under 40 years of age (over 70%).  Table 12 presents these age breakdowns.

Table 12. Age Distribution: Adult Head Injury Program

The majority of those served were males (72.5%). (See Table 13.)

Table 13. Gender:  Adult Head Injury Program

Proposed budget or appropriations has also increased over the past few years. (See Table 14.)

Table 14. Fiscal Appropriations: Adult Head Injury Program

Expenditures for the Adult Head Injury Program for FY 1999 and FY1998 are listed on Table 15.  In 1999 approximately 25% of the expenditures were in the category of transportation (25.4%), In-home supports (24.6%) and facility-based day activity (24.8%).

Table 15. Expenditures - 1998-1999

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Department of Social Services - Division of Aging

The mission of the division of Aging is to promote, maintain, improve, and protect the quality of life and quality of care for Missouri's older adults and persons with disabilities so they may live as independently as possible with dignity and respect.    The Missouri Division of Aging, Missouri Care Options program provides services both in community and long-term settings for those who are Medicaid eligible or potentially eligible and in need of assistance.  The types of in-home services include:

• Help with activities of daily living such as grooming, bathing, dressing, eating;
• Help with complex physical needs;
• A companion to relieve family caregivers, giving them time to run errands or attend to personal needs
• Help with housekeeping, laundry, meal preparation, shopping and other services
• In-home nursing care;
• Supervised adult day care programs; and
• Well-prepared, nutritious meals delivered to the home through arrangements with the Area Agencies on Aging.

The Division of Aging spent a total of $84,385,268 on home and community-based services in 1999.

Table 16 presents findings that reflect the number of individuals served by the Department of Social Services, Division of Aging programs.

Table 17 presents the Medicaid Services most likely impacted by the Olmstead decision.

Table 16. Significant Data Tables

Table 17. Programs Most Likely Impacted by Olmstead Decision

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Department of Social Services - Division of Medical Services

The Department of Social Services Division of Medical Services provides a variety of home and community-based programs.  The following tables show the Medicaid expenditures and numbers of persons served by:

• Missouri Medicaid State Plan Rehabilitation Services (Table 18);
• Missouri State Plan Targeted Case Management (Table 19);
• Missouri Medicaid Home and Community-Based 1915C Waiver Programs (Table 20); and
• Missouri Medicaid State Plan Programs (Table 21).

Index | Acknowledgements | Introduction | Activity 1 | Activity 2 | Activity 3 | Activity 4 | Activity 5 | Activity 6 | Activity 7 | Activity 8

Olmstead