The current Promoting Independence Advisory Committee1 (Committee) is very appreciative of the groundwork established by the previous Committees, and of the various advocate, consumer and provider communities supporting community-based services and supports. In addition, the Committee recognizes the contributions of the 81st Legislature and the Governor’s Office for supporting additional funding for community-based programs, especially during a very difficult period of economic downturn both on the national and state levels.
The Committee recognizes there are many competing interests during a legislative session requesting needed appropriations. Therefore, the Committee is grateful that while many other state legislatures have been in the process of downsizing programs and budgets, the state of Texas significantly increased its community-based funding for the 2010-11 biennium. The Committee acknowledges the difficulties that will be facing the 82nd Legislature (2011) and will be providing recommendations for the health and human services agencies’ 2012-2013 Legislative Appropriations Requests in order to keep Texas on the trajectory of meeting its original and subsequent Promoting Independence Plans and the requirements under the United States Supreme Court’s Olmstead decision (June 1999).
This report reflects the views and opinions of a consensus of the members of the Promoting Independence Advisory Committee (Committee); see Appendix A for information regarding the full membership of the Committee. When a member expresses a desire to abstain from any part of the report, that individual’s name and organization will be noted. Fiscal Year 2009 was a lesson in extremes. On the positive side, the Texas Legislature appropriated significant funding to increase the community-based services offered to individuals with intellectual and other developmental disabilities. Additionally, directives were given to promote reduction of the state supported living center census (formerly known as state schools) and to work toward allowing individuals a real choice in their residential settings. It is also expected that the number of individuals entering state supported living centers will be reduced as a result of the availability of funding for Home and Community-based Services (HCS) diversion services and activities specified under the 2010-11 General Appropriations Act (Article II, Special Provisions, Section 48, S.B. 1, 81st Legislature, Regular Session, 2009). The slots created through the diversion funding will be used specifically to prevent institutionalization in a state supported living center. All of these provisions support the goals of the Promoting Independence Advisory Committee (Committee).
At the same time, however, only minimal increases to support those with non-developmental disability services were approved, leaving individuals with other types of disabilities to question when and how the system will meet their needs. Exacerbating the issue was the recent announcement by the Department of Aging and Disability Services (DADS) that as a result of the 2010-11 General Appropriations Act (Article II, Special Provisions, Section 48, S.B. 1, 81st Legislature, Regular Session, 2009) not funding increased acuity for current waiver participants, the funds appropriated for new slots will be used to fund current waiver participants. The Community-based Alternatives (CBA) waiver program will be especially affected as DADS projects that no new slots will be made available. The number of new Community Living Assistance and Support Services (CLASS) and Medically Dependent Children Program (MDCP) slots will also be negatively affected while the HCS slots are expected to remain as originally projected.
While significant efforts were made during the 81st Legislature, Regular Session, 2009, to plan for reforming/redesigning the system of services for individuals with disabilities across populations and across programs, those efforts were not successful. Consequently, the fragmentation, the inequity in funding, and the confusion for the individuals trying to access services in the current system will continue. This will undoubtedly have a direct impact on the state’s ability to meet the goals of the Promoting Independence Plan (Plan).
Also affecting the state’s ability to meet the commitments of the Plan is the expected shortage of HCS slots for individuals requesting waiver services so that they may relocate from state supported living centers to HCS. DADS has indicated that current referrals from the state centers (as of August 2009 – before the biennium even begins) already exceed the number of slots targeted for state supported living center residents.
Additionally, efforts to provide meaningful wage increases for direct service and support providers were not successful, which will likely result in increased difficulty finding individuals to provide the needed services, putting the entire community system at risk. Compounding the problem is the reality that significant inequity continues to exist in the pay and benefits for community direct service and support workers compared to those working in state supported living centers, nursing facilities and other institutions. Rate discrepancies also continue to exist across community-based programs.
There is a significant concern in the lack of implementation of many of the recommendations developed by the Children in State Schools Workgroup, which was created by Executive Commissioner Hawkins in Calendar Year 2007; the final report was submitted in August 2008. From the beginning, reducing the number of children in the state supported living centers, and preventing new admissions of children, has been a key concern of the Committee. The Committee’s position continues to be that children with disabilities should have the opportunity to grow up in families with the supports and services they need.
Consequently, much work remains to be done and the work of the Committee is far from complete. The Committee recognizes the need to prioritize many of the issues that impact opportunities for individuals to access the services and supports needed in order for every Texan with disabilities to have a real choice on where they want to live to receive services. The Committee also recognizes that resources are limited and that the priorities of various interest groups often compete, creating the need to remain diligent in our efforts to ensure that every individual with a disability, who desires to do so, has the opportunity to live in their community. Until community-based services are as equally available as institutional services, the work of the Committee must focus on equalizing the system.
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Again, significant work remains. As a result of the unmet needs of Texans with disabilities, the Committee strongly urges the governor, legislative leadership, and the leadership of the Texas health and human services enterprise to address the following priorities:
- The need to develop a vision for a coordinated system of services and supports and a comprehensive strategic plan, with meaningful performance targets, to move the state towards the goals of the Plan. This vision and strategic plan should aim to eliminate all barriers to choice.
- The number of individuals on the waiting lists for all home and community-based services as of July 31, 2009 was 97,366 (unduplicated). Efforts must continue to fund community-based services for all individuals who prefer them as alternatives to institutional programs.
- HCS services must be made available to all those referred for community-based services from the state supported living centers. Referrals should not be reduced or delayed because of a shortage of targeted waiver slots.
- While progress has been made in reducing the number of children residing in institutions, significant work remains to ensure that all children with disabilities have the opportunity to grow up in families. Efforts to address the causes of institutionalization of children must accompany access to needed services prior to a child being institutionalized. Of particular concern is the lack of positive behavioral supports in community settings.
- The recommendations of the Children in State Schools Workgroup should be implemented as soon as possible. 
- Direct service workers are the backbone of long-term services and support programs. Although the positions require minimal training and qualifications, they are difficult to fill with qualified applicants. Across all service settings, direct service workers are likely to be compensated at or slightly above minimum wage, placing the positions at a competitive disadvantage. Once recruited, direct service workers have higher turnover rates than normal, given minimal or no benefits, hazardous working conditions, inadequate training, a lack of control over their jobs, and absence of a defined career ladder.
- Community-based direct service workers are doubly affected by such issues since their compensation is lower, on average, than institutional workers. Individuals and families can wait years to be offered waiver services only to find out that there is no one available to provide the services. Nursing facilities and other institutions continually suffer from significant staff turnover. Increased wages for direct service workers is the key component and should be addressed along with the need for other benefits and work incentives (see Workforce section for more detailed information).
- The Department of Justice Settlement Agreement was developed and approved without input from individuals, families, or other stakeholders. Disability advocates have expressed significant concern with respect to the changes to be made as a result of the agreement and the accountability for implementation, especially as the agreement relates to the Olmstead decision and “the most integrated setting.”
- The need to expand affordable, integrated, and accessible housing remains a significant barrier for those who want to relocate from an institutional setting. The Texas Department of Housing and Community Affairs recently expanded the number of vouchers through its Project Access program, but the limited number of vouchers (60) is inadequate to support all qualified applicants. In addition, the vouchers are restricted to applicants who are under the age of 62, placing older individuals at a disadvantage. Nursing facility residents, who are awaiting appropriate housing, are having their nursing facility stay significantly extended even after it’s been determined that they can receive adequate and less costly care in the community.
As new leadership arrives at both HHSC and DADS, the Promoting Independence Advisory Committee is hopeful that the Promoting Independence Plan receives the priority attention needed to ensure that Texas effectively complies with the Olmstead decision. Many recommendations have been developed that should be considered as part of a strategic planning process to ensure that Texas is ready for the needs of Texans with disabilities in both the near and long-term future.
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- The Preface is a statement made by a consensus of the membership of the Promoting Independence Advisory Committee. Each member may not agree to all statements and comments, however, in principle they agree to the overall content. Susan Payne, PART, Inc is on record in abstaining her support for the Preface as written.
- The Children in State Schools Report (August 2008) may be found in its entirety in the 2008 Promoting Independence Advisory Committee Stakeholder Report- Appendix G which may be found at: http://www.dads.state.tx.us/providers/pi/piac_reports/PIAC-2008.pdf
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July 16, 2010