Missouri's Olmstead Implementation |
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Activity No. 8: Recommend any modifications or changes that may be needed to improve existing home and community-based services and consumer-directed care programs. Background Discussion Background Discussion: If a person moves from an institutional setting to the community, there are many challenges that must be faced. The person has to find an affordable, adequate place to live. They must have the funding for a rental deposit. Then, they must have furniture, utility deposits, and enough money to start their household. Often when living in an institution, the person must relinquish their Social Security payment to the institution. This means when the person leaves the institution, they have no funding to be able to live in the community. General Public Comments: The participants to the Public Hearings made numerous comments about the transitioning of individuals with disabilities who are institutionalized and who are eligible for community-based treatment in community-based settings. Many of these comments focused on the needs of these individuals to live a full live in the community. I had shortly after my brain injury 21 years ago now I lived in a nursing home for awhile. It was a horrendous experience until I lived on a psych ward for over a year and that was a more horrendous experience. I was very luck. I had the support of services for independent living, the local independent living center here in Columbia that helped me get back into the community and I also had family support. Most of the people I work with now don't have that. (Columbia) If a person moves from an institution to a community setting, there is a period of time in which exceptional costs and support may be required. These can include startup money, moving expenses, and first month's payment. Homes frequently must be modified. Other kinds of temporary, one-time payments must be addressed. One speaker estimated that you're looking probably at over a thousand dollars to start off that these people have no way of saving up. (Cape Girardeau). One Kansas City speaker described the issues Yet are starting out with no credit ratings for deposits and lease signing, no home furnishings to set up a household. Once a home is established, nothing to do during the day, employment (Kansas City). Sometimes the services are not available in the community. This means that the person must enter or remain in the nursing home. Basically what they all said was we can provide you with a nursing home, but we can't provide you with anything in the community (Columbia). Even little things can make a difference in living in the community. In the Cape Girardeau hearing, this sentiment was presented. I mean we've been fortunate enough to get that stuff now but if we would get more people at it we might have a hard time coming up with a bed and a mattress, forks and spoons and pans. State Agency Information: The summary of comments reflect the comments of the Division of Comprehensive Psychiatric Services, Rehabilitation Services for the Blind, Department of Health, Division of Aging, Division of Alcohol and Drug Abuse, Division of Vocational Rehabilitation, and Division of Mental Retardation and Developmental Disabilities. There is significant variance across the agencies surveyed about the following questions from the Agency Survey. There were four issues discussed on the surveys that will be addressed here. These include:
The responses for each of the state agencies will follow. Each question is sequentially addressed in the agency descriptions. Return to the top of the page. Department of Elementary and Secondary Education, Current process for transition from an institutional setting to the community: The transition is usually from a nursing home. The center staff completes the assessment and identifies needs of the consumer (housing, attendant, training, utilities, furniture, etc.). It is important to determine not only if a consumer can live independently in the community with support, but is capable of self-directing his or her own care. The current time of transition can be a matter of days to a few months depending on the amount of support the consumer already has in place (e.g., family, living arrangements, attendant trained and ready, etc.) Additional supports needed for transition: Additional services could come from expanding the Independent Living Waiver. Additional support could come from amending the state plan to allow cognitively impaired consumers to select a "designee" to provide the consumer with care support services. Ideal process for transitioning individuals with disabilities: People in nursing homes (facilities) need to be able to set aside some of their Social Security check to provide some funds to set up housekeeping when it is time to re-establish themselves in the community. Nursing home (facility) residents are required to give up their assets when they enter the facility in order to qualify for Medicaid. Therefore, the consumers are unable to leave the facility when they are ready to transition to the community. Also, the Medicaid State Plan (MSP) only allows a maximum number of hours of personal care per month. Consumers who require more services must access additional services through the IL Waiver. However, there is currently a cap of 470 people on the waiver. One option to provide services to additional consumers would be to amend the IL Waiver by increasing the capacity to enable more consumers to access services beyond the scope of the MSP. How an individual is determined capable of living in a non-institutional setting: When leaving the nursing home, each center completes an 18 point assessment (the same tool as the Division of Aging). A team consisting of a center staff member (independent living specialist), a physical therapist/occupational therapist/nurse, and the consumer complete the assessment and determine needs. The Assistant Director, PAS, (DVR staff member) must approve the Plan of Care. Return to the top of the page. Department of Mental Health, Division of Alcohol and Drug Abused. Current process for transition from an institutional setting to the community: The Division of Alcohol and Drug Abuse funds 96-hour involuntary commitment beds for substance abuse consumers in St. Louis at St. Louis Metropolitan Psychiatric Rehabilitation Center (five beds) and at Western Missouri Mental Health Center in Kansas City (five beds). These are the only Division-funded services that occur in a state institution and are for the detention and assessment of persons who present a likelihood of serious harm to themselves or others as a result of alcohol or drug abuse or both. The commitment is for a period not to exceed 96 hours. The assessment determines if further treatment is needed. If so, a referral is arranged through voluntary means or a court order. Additional supports needed for transition: Not applicable Ideal process for transitioning individuals with disabilities: Not applicable How determine if an individual is capable of living in a non-institutional setting: Not applicable. Return to the top of the page. Department of Mental Health, Comprehensive Psychiatric Services Current process for transition from an institutional setting to the community: For persons who are hospitalized and persons in the Community Psychiatric Rehabilitation Consumer (CPRC) Program in the community, the treatment planning process involves the following: a quarterly review and an annual reassessment that provide for assessing when the individual is ready for a more integrated community setting and the process by which the transition will be made. In both cases, the assessment process is multidisciplinary. In the hospital it includes re-evaluation by a psychiatrist, nurse, and social worker. In the community it involves re-evaluation by staff from case management and psychiatry. The treatment plan must be rewritten at least annually or when any substantial changes in the individual's condition or treatment occur, and is updated quarterly. The treatment planning process is multidisciplinary and also includes participation by the person receiving services. Treatment plans commonly address skills that need to be developed to allow a person to move to more integrated settings such as budgeting, activities of daily living, and housekeeping. Treatment plans are always reviewed with the person receiving services and their signature is requested indicating their review. Specific to children, transition may include visits back and forth between the institution and community-based treatment setting according to the individual child's needs. Specific to adults, the transition may include visits to the community residence before actual transfer. Additional supports needed for transition: Some additional supports include more funding for community based supports such as targeted case management, comprehensive psychiatric rehabilitation, new medications, supported housing, and supported employment to make these services available to all people who are eligible; more community based mental health services for people with co-existing conditions (i.e. mental health and substance abuse or metal health and developmental disabilities).
The Department of Mental Health is currently developing best practices treatment models for these populations at both the inpatient and community-based level. Ideal process for transitioning individuals with disabilities: The process should be individualized to the person and their specific circumstances based on planning between the person and his or her treating professionals. How to determine if an individual is capable of living in a non-institutional setting: For persons who are hospitalized and persons in the CPRC Program in the community, treatment planning process involves the following: The quarterly review and the annual reassessment provides for assessing when they are ready for a more integrated community setting and the process by which the transition will be made. In both cases, the assessment process is multidisciplinary. In the hospital it includes reevaluation by a psychiatrist, nurse, and social worker. In the community it involves reevaluation by case management and psychiatry. The treatment plan must be rewritten at least annually or when any substantial changes in the individual's condition or treatment occur, and is updated quarterly. The treatment planning process is multidisciplinary and also includes participation by the person receiving services. Treatment plans commonly address skills that need to be developed to allow a person to move to more integrated settings such as budgeting, activities of daily living, and housekeeping. Treatment plans are always reviewed with the person receiving services and their signature is requested indicating their review. Specific to children, transition may include visits back and forth between the institution and community-based treatment setting according to the individual child's needs. Specific to adults, the transition may include visits to the community residence before actual transfer. Return to the top of the page. Department of Mental Health, Division of Mental Retardation/Developmental Disabilities. Current process for transition from an institutional setting to the community: All persons are assigned a service coordinator from a regional center and all persons have a person centered plan. This plan must address the needs and desires of the individual, including where the person wants to live. If the person wishes to live in the community, the regional center service coordinator will assist in identifying the supports which would be required, and begin work to secure those supports. Additional supports needed for transition: If a person chooses to leave an institution and move to the community and the person is unable to live in the community and chooses to return to the institution, attempts will first be made to adjust/improve community supports to better meet the person's need. If this is not satisfactory, and the person wants to move back to the institution, the person will be accommodated. Ideal process for transitioning individuals with disabilities: This is described above. How determine if an individual is capable of living in a non-institutional setting. A state treatment professional will determine if the person was voluntarily admitted or court ordered to the institution. Treatment professionals will next determine if the person is a danger to himself and/or others. Finally, the treatment professionals will evaluate the person's services and support needs and determine if the needs can be met in the community so that the person's overall health and safety can be maintained. The person may need opportunities to visit other living arrangements in the community in order to determine the person's interest in relocating to the community. Return to the top of the page. Department of Health, Adult Head Injury Program Current process for transition from an institutional setting to the community:The Service Coordinator assists in transition from hospitals to nursing homes and from nursing homes to community. The Service Coordinator intervenes by assisting in planning and setting up services. The Department of Health, along with other agencies, provides services. The Service Coordinator finds resources and ways of funding the services. The Missouri Head Injury Advisory Council also provides valuable information to assist in the transition process. Additional supports needed for transition: Additional provider support close to the individual's home and community, particularly in rural areas, is needed. One example of more provider support would be in the areas of Personal Care Assistants (PCAs). A system of transportation that would be more readily available to clients was also suggested, as well as accessible recreation activities. Ideal process for transitioning individuals with disabilities: Implementing the Person Centered Approach throughout the process is critical. This would entail speaking with the person and his/her family about what they want. Public funding and natural supports would also have to be available. The Adult Head Injury Program service coordinator's role is to assure that everyone important in the individual's life is working together toward the plan for community inclusion and independence. How to determine if an individual is capable of living in a non-institutional setting: There is no process in place. However, the Department of Health is developing an assessment tool for the program and the future Traumatic Brain Injury (TBI) waiver. Return to the top of the page. Department of Social Services, Division of Aging Current process for transition from an institutional setting to the community: The Division of Aging (DA) case managers meet with the individual and/or their representative to discuss support systems, met and unmet needs, medical considerations, social concerns, activities of daily living, housing, and all other issues involved in community living. The case manager utilizes the DA assessment tool to guide the discussion and identify needs. Multidisciplinary teams may also be utilized to develop the plan of care for a particular individual. This could include institutional staff, family members, or provider agency staff. Ombudsman volunteers, Area Agencies on Aging (AAAs), Centers for Independent Living, Department of Mental Health (DMH), other agencies, and the DA case manager. The team would identify specific services needed. Once a person returns to the community, the DA case manager follows up with the consumer as needed to ensure that the care plan is adequate to meet his or her needs. Additional supports needed for transition: In many cases an individual needs 24 hour oversight. DA services are not, by design, intended to be the only support system available and every effort is made to coordinate with other agencies and resources. Other major areas of concern include the need for affordable/accessible housing, assisted transportation, respite care, direct support or caregivers, and the funding necessary to make the transition back to community living. The ability to provide assistance in each of these areas is linked to the requisite corollary fiscal support. Ideal process for transitioning individuals with disabilities: Discharge planners/social workers within nursing facilities are in an ideal position to identify and work with person who wishes to return to a community setting. Designation of the lead agency would be imperative in situations that involve multiple agency programs. Establishing a multidisciplinary team to identify needs and potential resources would also be necessary components. The plan of care would be developed with input from all parties concerned, especially the consumer, family members, physician, provider agency, and other significant persons or agencies. Professional staff support would be provided to those customers who choose to self-direct their care, and the designated case manager would be given responsibility for the coordination of services, communication between all parties involved, and any necessary follow up activities. Any subsequent problems or concerns would be resolved with input from the team. How to determine if an individual is capable of living in a non-institutional setting:The individual's self-assessment and choice is a critical part of this process. DA has a comprehensive assessment process to determine an individual's functional limitations, living arrangements, support systems, medical issues, financial resources, and the risk of abuse, neglect, or exploitation. The assessment is utilized to develop a service plan in line with consumer choice which addresses the individual's unmet needs. DA case managers consult with agency nurses, supervisory staff, provider staff, and other professionals as necessary to assure the consumer's safety and welfare in a community setting. Return to the top of the page. Department of Social Services, Rehabilitation Services for the Blind Current process for transition from an institutional setting to the community: The Rehabilitation Services for the Blind (RSB) would upon referral provide eligible blind/visually impaired individuals with rehabilitation teaching services, including Braille, travel, cooking, skills of daily living, etc. as needed to live independently. Additional supports needed for transition:Blind/visually impaired seniors may need a comprehensive array of service to return home. Ideal process for transitioning individuals with disabilities: The "Ideal Process" would depend on the individual and their needs. How determine if an individual is capable of living in a non-institutional setting: RSB staff does not typically make this kind decision. Information is offered on the independent living skill level of an individual. Identification of Barriers and Recommendations from the Olmstead Committees: Following are barriers and related recommendations from the Olmstead Committees related to transition from institutions to community living. Barriers: People who are in nursing homes have to sue their SSI checks to pay for nursing home care at the first of the month. Thus, people never have money to move into the community and cover transitional costs such as rent deposits, utilities, etc. One months SSI payment is probably not enough to cover all costs.
Barriers: Schools are not involved in helping students with disabilities to get into community services and community life. Under IDEA, schools are mandated to provide transition services to children who reach age 14 or 16. Special education students are supposed to have a transition plan included in their Individual Education Plan (IEP). Sometimes this is referred to as transition from school to work, but it also includes transitioning from school to "independent living." The Department of Elementary and Secondary Education (DESE) had a grant to cover transition services, but the grant funding is running out. In Missouri SB321 was passed by the 87th General Assembly, but it was never funded.
Barriers: There are many aspects of transition from an institutional setting to a community setting that require individualized attention.
Timelines & Responsible Parties: The Commission has reviewed the issue of waiting list movement for people with disabilities who are eligible for community-based treatment. It is critical that proper timeframes for movement through these processes be developed, but premature to develop before the processes are finalized. The Commission recommends that each agency develop and implement these timelines after assessing their waiting lists, their resources, and assessment processes. We recommend that as part of the Commission's on-going charge, the Commission review these timelines for appropriateness and true movement. This review should be completed and reported on by June 30, 2001. The following table summarizes recommendations, identifies agency(ies) responsible for planning and initiating activities to realize each recommendation, and identifies the calendar year in which the results will be achieved: The code for state agencies is:
Recommendations: 1a. Develop and fund Olmstead Transition Fund to be administered by Governor's Council on Disability.
1b. The state should look for unique ways in which to fund some of the needs of people with disabilities who transition from institutions to community settings, including but not limited to, bringing in private sector for donations of furniture or adaptive equipment, using public agencies to assist with utility deposits and rental deposits, using interest free loans.
1c. Lobby for a discretionary fund to cover emergencies and unique needs to help avoid institutional placement of any individual.
2. Recommend that Missouri SB321 (Transition Advisory Council) is fully funded.
3. A person-centered planning process should be conducted with each person that transitions from the institution to a community setting. This process should follow the person into the community to assure that the supports needed in the community are available.
Budget Action, Federal Action, and Statute Changes. Needed Budget Action:
Federal Action:None required. Statute Changes:None required. Index | Acknowledgements | Introduction | Activity 1 | Activity 2 | Activity 3 | Activity 4 | Activity 5 | Activity 6 | Activity 7 | Activity 8 |
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