2010 Promoting Independence Plan Recommendations
The following recommendations are made for program funding and service system delivery and are designed to meet the intent of the Olmstead decision, two Executive Orders (see Appendix B) and S.B. 367 and S.B. 368, 77th Legislature, Regular Session, 2001. These recommendations for the 2010 Revised Promoting Independence Plan (Plan) continue the work of the original Plan and will help Texas reach its ultimate goal of individual choice and self-determination.
All implementation recommendations from the previous Plans remain in effect.  The 2010 recommendations build upon those previous Plans. The 2010 Plan groups twenty-four recommendations into three major sections. Within each section, several recommendations are made with background information. The Health and Human Services Commission (HHSC) will make health and human service agency assignments and coordinate activities across state agencies as necessary. It is recognized that many of the recommendations are contingent upon Legislative direction and, when necessary, appropriations. The Promoting Independence Advisory Committee (Committee) will monitor agency progress in implementing each recommendation.
HHSC, based on the Committee’s recommendations made in its 2010 Promoting Independence Advisory Committee Stakeholder Report, has included the following implementation recommendations that address the barriers identified in providing community-based programs and promoting individual choice. The recommendations are numbered for ease of reference and do not reflect level of importance in relation to the other recommendations. It should be noted that the following recommendations do not include all the recommendations made by the Committee and in some instances language has been modified. 
This chapter is divided into three major sections and then subdivided into topic areas; the three sections are:
- Section I: Do No Harm
- Section II: Efficiencies in the Existing System
- Section III: Increased Community Options
SECTION I: DO NO HARM
Texas has made great strides during the last three Legislative Sessions (2005, 2007, and 2009) in meeting its obligations to the United States Supreme Court’s Olmstead v. L.C. decision (1999) and its own Plan. It is important that those achievements be considered when addressing the difficult budget considerations. Restrictions in waiver funding will result in fewer individuals having opportunities to choose community-based services.
SECTION II: REALIZE EFFICIENCIES IN THE CURRENT SYSTEM
The following recommendations focus on the streamlining of the health and human services system as envisioned with the passage of H.B. 2292, 78th Legislature, Regular Session, 2003. One of the goals of H.B. 2292 is for an efficient and effective long-term services and supports system.
1. Requires legislative direction.
If directed by the Legislature, HHSC will expand the long-term services and supports managed care system (STAR+PLUS) to Lubbock, El Paso, the Rio Grande Valley.
STAR+PLUS is currently in four large metropolitan service delivery areas: Bexar Service Area (seven counties); Harris Expansion Service Area (seven counties); Nueces Service Area (nine counties); and Travis Service Area (seven counties). STAR+PLUS is scheduled to be implemented in the Dallas Service Area (seven counties) and the Tarrant Service Area (six counties) in February 2011. HHSC included Exceptional Item 17 in its Legislative Appropriations Request. The savings by expanding STAR+PLUS and other changes to the program is projected at $28,940,877 million general revenue (GR).
2. Match the current general revenue allocation for the Relocation Activity with Medicaid administrative match.
Texas currently funds its relocation activity with general funds. These funds come primarily to DADS and a transfer from HHSC, the total amount is approximately $4 million (GR). The relocation activity funds relocation specialists to assist nursing facility residents with complex medical/functional needs to relocate to the community if that is their choice. Texas has administered this activity since calendar year 2002 and has the utilization history to predict future costs. Many states have similar activities and use Medicaid administrative match to enhance state general revenue dollars. Using Medicaid match can effectively double the state general revenue appropriation and increase the number of relocation specialists.
3. Requires legislative direction and/or appropriations.
If directed and/or funded by the Legislature, create an “at-risk” pool of slots for individuals at imminent risk for nursing facility placement.
The 2010-11 General Appropriations Act (Article II, Special Provisions, Section 48, S.B. 1, 81st Legislature, Regular Session, 2009) funded 196 Home and Community-based Services (HCS) slots for individuals with intellectual and developmental disabilities (IDD) at-risk for placement in an intermediate care facility for persons with MR (ICF/MR) as a result of emergency or crisis situations. The 82nd Legislature should create a similar provision for individuals at-risk for placement in a nursing facility as a result of emergency or crisis situations. The Department of Aging and Disability Services (DADS) Legislative Appropriations Request (LAR) Exceptional Item 4 requests funding for this activity as part of its larger Promoting Independence request.
4. May require legislative direction and/or appropriations.
If directed and/or funded by the Legislation, HHSC will work with DADS to expand its Aging and Disability Resource Centers (ADRCs) network.
Individuals with disabilities and their advocates often experience difficulty accessing in-home services and supports because of the complexity of the human service network and lack of integration between federal, state, and locally-funded services. Texas has invested in model programs that better integrate services by providing seed funding for ADRCs, located in nine communities in fiscal year 2010 with two more to be added in fiscal year 2011. Although local communities may design the ADRCs using a “single point of entry” or “no wrong door” system of accessing services, all ADRCs are intended to expedite consumers’ access to long-term services and supports. This recommendation is included in DADS LAR as Exceptional 5, which will continue support for the existing ADRCs (at $100,000 each per year) and to establish three additional Centers, at $200,000 each per year, for a total of an additional $3.7 million GR for the fiscal 2012-2013 biennium.
5. Requires legislative direction and/or appropriations.
If directed and/or funded by the Legislature, DADS will increase the number of nursing facility diversion programs.
Money Follows the Person has provided real choice to individuals on Medicaid who live in nursing facilities by allowing them immediate access to the Community Based Services (CBA), Community Living Assistance and Support Services (CLASS), Medically Dependant Children Program (MDCP), STAR+PLUS, and HCS (only for children 0-22 years of age) waiver programs; however, with a large CBA interest list on which individuals are placed by referral date, with no consideration for their risk of institutionalization, the system does not provide targeted diversion prior to placement in an institution.
DADS has received grants from the Administration on Aging (AoA) to create nursing facility diversion projects in Central Texas and Tarrant County known as Community Living Programs. This program is characterized by the pooling of Title III and GR funds, along with cost sharing, to create intensive supports for individuals who are at greatest risk of nursing facility placement. The Community Living Program has proven successful in diverting individuals who are in a spend-down mode from institutional stay into less costly community-based programs.
6. Increase outreach and education efforts regarding nurse delegation. Work with the Board of Nursing to educate their membership on nurse delegation as it pertains to long-term services and supports.
Nurse delegation is an important option to promote independence and to make possible community-based living. Issues regarding nurse delegation as defined under Chapter 225 impact all of DADS and HHSC’s long-term services and supports programs. This recommendation is to enhance outreach and educations efforts with the Board of Nursing and their constituency.
7. Requires legislative direction and/or appropriations.
If directed and/or funded by the Legislature, HHSC will work with the Department of State Health Services (DSHS) to increase the number of “restoration of capacity” pilots across the state.
Many individuals in Texas state hospitals are there for restoration of capacity to be adjudicated. Many of these individuals have committed misdemeanor offenses and could receive mental health restoration services more effectively in the community, leaving the state hospital beds for those in severe crisis. Currently four community restoration pilots exist that have shown positive results as well as cost savings. Texas should expand the community restoration projects to allow more individuals to receive community restoration services and avoid institutionalization. This would generate a cost savings for the state.
8. Improve hospital discharge planning services and standards with an emphasis on community-based planning.
Although hospitals are required to provide discharge planning services, they are not required to provide high-risk consumers with written discharge plans before they leave the hospital, and need not obtain written documentation of consumers’ agreement with such plans. As a result, some consumers return to the community without critical long-term services and supports; some receive fewer supports than are necessary; and others are provided institutional services (e.g., nursing facility care) that are not of their choosing and inconsistent with their preferences.
DSHS should review its standards for hospital discharge planners with a focus on high-risk consumers and work with DADS to help discharge planners with: (1) comprehensive information about community-based services that allow the consumer to remain in the most integrated setting; (2) assistance in accessing those services as needed; and (3) a written plan of care before being discharged from the hospital.
In addition, DSHS and DADS need to assist the discharge planner with information about community-based services.
SECTION III: RECOMMENDATIONS TO INCREASE COMMUNITY OPTIONS AND SUPPORT PROMOTING INDEPENDENCE
Part A: Recommendations for change and funding for the 1915(c) waivers.
9. Requires legislative direction and/or appropriations.
If directed and/or funded by the Legislature, increase Medicaid 1915(c) slots.
The Committee’s number one priority is that the emphasis on increasing community-based services be continued and enhanced by the 82nd Legislature. HHSC has included Exceptional Item 23 to its LAR which increases DADS community services capacity by providing an average monthly caseload increase of 3,928 in fiscal year 2012 and 11,785 by fiscal year 2013. The Department of Assistive and Rehabilitative Services (DARS) - $7.4 million GR & All Funds (AF). DARS’ programs included in this exceptional item are Independent Living Service (ILS) & Comprehensive Rehabilitative Services (CRS). This exceptional item provides services for an additional 625 individuals in the CRS program & 1,760 individuals in the ILS program. DSHS - $53.8 million GR & AF. DSHS’ programs included in this exceptional item are Child and Adolescent Community Mental Health (CACMH), Adult Community Mental Health (ACMH), & Children with Special Health Care Needs (CSHCN). This exceptional item provides services for an additional 4,056 individuals in ACMH, 277 individuals in CACMH, & 87 individuals in CSHCN. The total request is for $265,423,701 million GR.
10. Requires legislative directions and/or appropriations.
If directed and/or funded by the Legislature, increase funding to all the existing 1915(c) waiver programs in order to ensure flexibility in the service array.
1915(c) waiver programs have set service arrays to help manage utilization and overall costs. Many of these programs currently exist with the same service arrays that were established in the mid-1980s and 1990s when the programs were first created. Through experience, there are many other support services that could be offered that would enhance success in community living and an individual’s quality of life. Examples of services currently not offered are behavioral health supports, services to support an individual with traumatic brain syndrome, services to support an individual with autism, and other specific supports. These additional services and supports may not necessarily increase the overall cost cap but rather provide increased flexibility and opportunity for an individual’s self-determination.
11. Requires legislative directions and/or appropriations
If directed and/or funded by the Legislature, HHSC with DADS should establish a Hospital Level of Care Waiver.
It is recommended that HHSC with DADS establish a 1915(c) waiver to serve individuals who currently exceed waiver cost caps and are being funded with GR. These individuals have significant medical and functional needs. The recommendation is made with the caveat that the state received CMS approval to allow a cost-neutral program not dependent on additional GR.
Part B: Fund behavioral health services and supports for health and human services enterprise programs.
There is an increasing concern for the lack of behavioral health services and supports for individuals with a mental illness and/or a substance abuse. These issues, as either stand-alone concerns, or coupled with a co-occurring other disability presents a barrier for a fully-integrated long-term services and supports system. It is difficult to be in full compliance with the Olmstead decision when many of the barriers to community integration and relocation from institutional settings are dependent on limited behavioral health funding. The following three behavioral health recommendations are:
12. Requires legislative direction and/or appropriations
If directed and/or funded by the Legislature, fully fund DSHS’ Assertive Community Treatment (ACT) Service Packages as part of the Resiliency and Disease Management (RDM) Program.
DSHS has recognized the importance of the Initiative and those individuals who have been hospitalized for over a year as part of the Promoting Independence (PI) population. DSHS has also acknowledged that the focus should incorporate those individuals who are at risk of hospitalization and for individuals who have been hospitalized 2 or more times in 180 days. The Plan formally targets individuals with 3 or more hospitalizations within the 180 day period. However, DSHS’ RDM allows for services to individuals with the two or more hospitalizations in order to help prevent a third hospitalization.
DSHS has determined that the at-risk population should be incorporated into the RDM System regardless of diagnosis, and that generally adults are appropriate for service level 4 of ACT. The current appropriations are not adequate to meet the capacity of the state and a significant number of individuals are being recommended for ACT level 4 but are actually enrolled into a less intensive and expensive level of services. According to the DSHS strategic plan, an estimated 970,393 adults in Texas met the DSHS mental health priority population definition in fiscal year 2010, approximately 467,226 are estimated to have the greatest need (targeted priority population). DSHS program service utilization data indicates that an approximate one fourth of those with the greatest need received mental health services from the state authority in 2010.
13. Requires legislative direction and/or appropriations
If directed and/or funded by the Legislature, DSHS should provide services and supports for individuals leaving the state mental health facility (state hospital) system.
Many individuals leaving the state hospital system have no community residence or the required services to help them re-integrate back into community living. This lack of services and housing options result in a large percentage of individuals being discharged from the state hospital into a nursing facility. The state then works with that individual through the “money follows the person” (MFP) policy to have him/her return to the community. This process is costly to the state and does not provide the highest level of a quality of life to the individual. It is recommended that DSHS is provided sufficient funding to provide the necessary community services and supports, such as Cognitive Adaptation Training.
14. Requires legislative directions and/or appropriations
If directed and/or funded by the Legislature, HHSC will work with DADS to include behavioral health services and supports as service options within all Medicaid 1915(c) waiver programs including STAR+PLUS.
The current 1915(c) service arrays do not adequately cover behavioral health services and supports in the waivers for individuals with intellectual and developmental disabilities; and not at all for the waivers covering individuals with physical disabilities. Therefore, community options are limited for those individuals with a co-occurring physical, intellectual, or developmental disability. It is recommended that all Medicaid 1915(c) waiver programs provide behavioral health services and supports as a service option under the service array. While the addition of this service option may initially increase the individual service plan cost, this could be a short-term activity until the individual stabilizes or eventually offset other service costs as a result of a reduction for the need of other available services.
Through the Money Follows the Person Demonstration (Demonstration), the state is conducting a pilot project in Bexar County and the City of Austin. This pilot is providing two behavioral health services (Cognitive Adaptation Training and Substance Abuse Services) in addition to the STAR+PLUS service array. Preliminary data indicate that the need of certain STAR+PLUS services actually decrease with the delivery of these two behavioral health services.
Part C: Other funding recommendations.
15. Requires legislative directions and/or appropriations
If directed and/or funded by the Legislature, fund an integrated data warehouse.
The long-term services and supports system crosses several health and human services operating agencies. DADS, the lead operating agency for long-term services and supports, is in the process of enhancing its “data warehouse” which provides individual service level information for purposes of providing data to make evidence-based policy decisions. However the managed care system, which has expanded into all of the major urban service delivery areas and is administered by HHSC, maintains its own data collection process. It is important to create a single “data warehouse” which will integrate both the fee-for-service and managed care data. There is a significant need to characterize the entire long-term services and supports systems within a single system, and discuss in an evidence-based manner, the commonalities and differences of the two funding systems.
WORKFORCE AND PROVIDER NETWORK STABILIZATION
The opportunities for community living are limited without a functional, available, and qualified work force and provider network. Significant turnover rates for direct services and supports staff result in an additional expense for recruiting and training new employees. Lack of sufficient funds to address these expense items may have an equally negative impact on the quality of services provided and the availability of a qualified provider base from which an individual may choose to receive services.
16. Requires legislative directions and/or appropriations
If directed and/or funded by the Legislature, fully-fund the 2010 Consolidated Budget’s 2012-2013 rate methodology requests.
HHSC published its 2010 Consolidated Budget in October 2010. HHSC, in the past, lays out the cost implications for increasing provider rates by certain intervals. The state has published rate methodologies in the Texas Administrative Code but does not fully fund those formulas. The following Table indicates the amount requested in the 2010 Consolidated Budget and the amount appropriated:
TABLE 1: 2010 Consolidated Budget Request
Appropriated by 81st Legislature
|| 8.08 %
|| 9.96 %
|| 5.11 %
|| 4.11 %
|| 3.42 %
17. Requires legislative directions and/or appropriations
If directed and/or funded by the Legislature, increase dedicated funding for community direct services and supports workers.
The ability to recruit and retain direct services workers is at a critical juncture in Texas. Without a stable direct service workforce, it will be difficult to have a quality community-based system. HHSC requested DADS to convene a Workforce Advisory Committee to study and make recommendations on how to better retain direct services workers. The number one recommendation was to increases direct services wages that, for the most part, are at or near minimum wage. The cost of various provider rate changes (presented in one percent increments – Chapter VIII, Table VIII.1 and Appendices C1-C2) includes attendant compensation increases.
The state must continue to address the number of children with disabilities who continue to remain in Texas institutions and those children with disabilities at-risk of institutionalization remain with families.
The following recommendations are aimed at decreasing the number of children with disabilities in Texas institutions, increasing access to quality permanency planning and family-based options, and preventing new admissions of children to these facilities.
18. Requires legislative directions and/or appropriations
If directed and/or funded by the Legislature, continue to provide the appropriate community-based services to those at imminent risk of institutionalization and prevent the placement of children/youth 17 years and younger in institutional settings.
The 81st Legislature (2009) funded 196 “diversion” slot (96 for children, 100 for adults) who were at imminent risk of placement into a state supported living centers (SSLC). These slots have been very valuable in allowing an individual a choice when their circumstances would have forced them into a SSLC. DADS’ LAR Exceptional Item 4 requests an expansion of this number to 240 slots.
19. Requires legislative directions and/or appropriations
If directed and/or funded by the Legislature, expand the Promoting Independence (PI) population to include children in institutions licensed by DFPS (for children in state conservatorship).
Being designated as a PI population provides a child/youth with immediate or expedited access to the HCS waiver programs. Currently, the PI population only includes individuals in nursing facilities, state supported living centers, and nine or more bed community ICFs/MR. DFPS administers three facilities that serve children with developmental disabilities in their conservatorship. These children must wait for a foster family or be on the HCS interest list which may result in several years.
20. Requires legislative directions and/or appropriations
If directed and/or funded by the Legislature, develop specialized ICFs/MR that offer short-term stays to provide behavioral supports to stabilize an acute situation for children with disabilities needing out-of-home placement.
This recommendation would increase the number of specialized ICFs/MRs across the state that provide intensive, short-term (three to six months) behavioral support services. These services would be based on a similar program in Richmond, Texas, known as the Behavior Training and Treatment Center (BTTC). DADS LAR Exceptional Item 6 requesting funding to provide two specialized ICFs/MR in each of the 12 SSLC areas. An additional $18,789,246 million GR is required to fund this activity.
INDEPENDENT LIVING OPPORTUNITIES AND RELOCATION ACTIVITIES
21. Requires legislative directions and/or appropriations
If directed and/or funded by the Legislature, fund Department of Assistive and Rehabilitative in order to add three additional Centers for Independent Living (CILs).
The federal Rehabilitation Act which is overseen by the Rehabilitation Services Administration created the development of CILs. The purpose of the independent living programs is to maximize the leadership, empowerment, independence, and productivity of individuals with disabilities and to integrate these individuals into their communities. CILs provide services to individuals with significant disabilities that help them remain in the community and avoid long-term institutional settings.
Prior to the 81st Legislative Session, there were 23 CILs in Texas funded by federal and GR funds which covered only 161 counties. The 81st Legislature added funding to the 2010-11 General Appropriations Act (Title II, DARS, S.B. 1, 81st Legislature, Regular Session, 2009) to create three new CILs covering Collin County, Galveston County and Tom Green County. Overall coverage by the 26 CILs includes 164 counties. Nevertheless, many parts of the state, especially in the rural counties, are without CIL coverage (90 counties are without Title VII, Part C, CIL funding).
Affordable, accessible, and integrated housing is an essential base requirement for individuals who want to relocate back into their communities.
Individuals who are relocating from nursing facilities or individuals who are in the targeted Olmstead populations under the DSHS provisions must have integrated and affordable community housing. There are two substantial barriers: the poverty of individuals who are living at the Supplemental Security Income (SSI) level ($674/month); and/or the lack of easy access to wrap-around supports and services.
22. Increase the number individuals over 62 years of age who are eligible to access Project Access vouchers.
HHSC will request the Texas Department of Housing and Community Affairs (TDHCA) to continue to increase the number of voucher under its Project Access program and make them available to all individuals with disabilities regardless of age. Project Access was created as a Section 8 voucher program funded through the United States Department of Housing and Urban Development (HUD) and administered through TDHCA. It provides permanent housing vouchers versus the more common two-year voucher (Tenant-based Rental Assistance). Project Access vouchers are dedicated Section 8 vouchers for individuals leaving institutional settings. Historically, the only limiting factor for Project Access was that they could only be used by individuals 0-62 years of age.
The federal program ended calendar year 2003 however, TDHCA chose to continue the program with permission from HUD. TDHCA is funding the program through its HOME program allocation and until recently has chosen to continue the 62 age limitation; this was changed in fiscal year 2011 when TDHCA dedicated twenty percent of the Project Access vouchers for individuals who are 63 and older. Because fifty-seven percent of the nursing facility population that chooses to relocate back into the community is over the age of 60, it is important that older Texans have equal access to these vouchers.
23. When possible, TDHCA should continue to increase the amount of dedicated HOME vouchers for individuals relocating from institutional settings.
TDHCA administers HOME vouchers which provide both temporary (two year Tenant Based Rental Assistance) vouchers for individuals who are relocating from institutional settings. There is always an increasing need for accessible, affordable, and integrated housing for individuals who are at the SSI level of income (16-20 percent of average median income).
24. Requires legislative directions and/or appropriations
If directed and/or funded by the Legislature, increase funding for the Housing Trust Fund (Fund).
The State of Texas has a Fund (GR) to provide discretionary funding for specific housing supports to the general public. The 2010-11 General Appropriations Act (81st Legislature, Article VII, TDHCA, S.B. 1, Regular Session, 2009) increased the Housing Trust Fund (Fund) from $5 million (GR) to $10 million (GR) per annum. The Fund is the only source of GR for funding various supportive housing issues including individuals with disabilities; e.g. the Amy Young Barriers Removal Program. TDHCA included Exceptional Item 10 to increase appropriations for the Fund by $4 million per annum ($8 million for the biennium).
- To access the original Plan and the subsequent revisions, go to the DADS website at: http://www.dads.state.tx.us/providers/pi/independence_plan.html.
- To review the Committee’s full text of all recommendations in the 2010 Promoting Independence Advisory Committee Stakeholder Report, go to the DADS website at http://www.dads.state.tx.us/providers/pi/piac_reports/index.html, or see Appendix F.
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May 24, 2011