Appendix G

Texas Department of Aging and Disability Services: Accomplishments Related to Promoting Independence – State Fiscal Year 2010

Legislative Initiated Activities

Much of the work accomplished at the Texas Department of Aging and Disability Services (DADS) relating to the goals of the Promoting Independence Plan was driven over the past year by actions of the 81st Texas Legislature through S.B. 1, the General Appropriations Act, including Riders, and in separate legislation.

These accomplishments include:

Responses to S.B. 1:

Movement of HCS Case Management to MRAs effective 6/1/10: HCS and Service Coordination rule changes were adopted on 6/1/10. Activities include:

Provided regular updates to Frequently Asked Questions related to the transition;
Posted HCS program handbook for HCS providers and MRA staff on the DADS website;
Executed changes to the CARE database to implement this initiative;
Conducted six training sessions for HCS providers and MRA staff in April and May of 2010. Training was held in San Antonio, Houston, Fort Worth, and Lubbock;
Sought CMS approval of the HCS waiver to remove case management as a service offered by the HCS program providers; and
Developed HCS contract amendments to remove case management services.

Relocation Activities to Assist Individuals in Nursing Facilities to Relocate Back into their Community.
- DADS received appropriations for Relocation Services maintenance and expansion which increased funding from $1.3M – GR/$1.9-AF to $3.4M-GR/$4M-AF.
- Funds were allocated to contractors for Relocation Services and Transition to Life in the Community (TLC) for FY 2010. Contract amendments for new allocations were effective September 1, 2009.

Implementation of Rider 32: Services under a 1915(c) Waiver. Children who are 21 years of age and younger, who reside in nursing facilities, may by-pass the HCS interest list to receive HCS services. Between September 1, 2009 and July 1, 2010, 14 individuals have received an offer of HCS through this Rider.

Implementation of Rider 33: Services under HCS Waiver Program. There have been no instances whereby individuals referred for HCS services from community ICFs/MR were determined to be ineligible for HCS services.

Implementation of Rider 34: Promoting Community Services for Children. 50 HCS slots have been set aside. As of July 1, 2010, 25 HCS slots have been released and 15 individuals enrolled. The allocation of 50 will be released at 25 slots per fiscal year.

Implementation of Rider 36: Waiver Cost Limits. DADS Access & Intake has hired staff specifically to track and manage the General Revenue (GR) process for these consumers.

Rider Section 36a: Individual cost limits for waiver programs have been set according to Rider requirements.
Rider Section 36b: Ten consumers are receiving waiver services above the individual cost limit funded by GR. Of the ten, one individual receives waiver services above the cost limit in accordance with the prescribed use of GR Funds under Rider 36; five consumers who exceeded the individual cost limit as of 9/1/05 continue to receive services funded by GR in accordance with provisions of Rider 36(b) (2); and four receive waiver services above the cost limit funded by GR due to settlement agreements. For the time period September 2009 through July 2010, eight consumers received clinical assessments for Rider 36. Of the eight none were approved for Rider 36 funding.
Rider Section 36c: DADS has implemented utilization review (UR) in waiver program areas.

Implementation of Rider 37: Expenditure of Settlement Funds. Efforts are on-going to ensure timely completion of all required activities including:

The independent settlement agreement monitors have completed 13 baseline reviews as of 5/14/10. Reports for the first nine facilities reviewed (Corpus Christi, Brenham, El Paso, Austin, Mexia, Lubbock, Abilene, Rio Grande and San Antonio) are posted on DADS’ website at: http://www.dads.state.tx.us/monitors/reports/index.html.
Monitoring visits began the week of July 12, 2010, at the Corpus Christi State Supported Living Center.
DADS plans of improvement have been reviewed and revised based on the initial baseline reports. DADS continues to work with the DOJ and the independent settlement agreement monitors to meet the intent of the settlement agreement.

Implementation of Section 48(a) of Special Provisions for all Health and Human Services Agencies in S.B. 1. Requires DADS to reduce the number of state supported living center (Center) residents through census management without removing a resident from a Center against the wishes of the resident or the resident’s legally authorized representative. Data relevant to movement of individuals to and from each of the Centers is now being evaluated on an ongoing basis to project census at each of the Centers.

Projections for census and staffing needs are being developed for future decisions on resource allocation based on guidance from this section of the Appropriations Bill. Census at the Centers continues to decline as noted in the table below:

	Sep-08	Sep-09	May-10
Abilene	510	483	460
Austin	426	398	383
Brenham	384	378	349
Corpus Christi	352	323	297
Denton	617	582	552
El Paso	139	142	137
Lubbock	266	242	232
Lufkin	424	414	406
Mexia	505	477	434
Richmond	494	463	416
Rio Grande	75	72	71
San Angelo	289	272	251
San Antonio	288	286	281
All Facilities	4769	4532	4269

Implementation of S.B. 271

On August 3, 2010, DADS regional Community Services intake staff implemented the Caregiver Status Questionnaire (CSQ) process. S.B. 271 directs DADS to collect caregiver profiles and perform outreach functions to informal caregivers in an effort to raise awareness of services available to caregivers and to gather data about the needs of caregivers. Regional intake staff are now required to request whether an applicant for DADS Community Services has a caregiver. If a caregiver is available, information is requested of the caregiver and is captured in the automated intake system (a.k.a. NTK). Caregivers are provided with information about caregiver resources available in their area.
On August 9, 2010, DADS Access and Intake/Area Agencies on Aging section deployed the Caregiver Assessment Questionnaire (CAQ) through the State Unit on Aging Program Uniform Reporting System (SPURS). The CAQ incorporates the caregiver profile question, which is also being implemented by regional staff through the CSQ process, in addition to assessing the needs of caregivers accessing services through area agencies on aging (AAAs). AAAs are required to implement the use of the CAQ and to enter the data into SPURS once the AAA has achieved "Go Live" in the system. Full utilization of the CAQ by AAAs is expected to be achieved in fall of 2010.
Data retrieved from both systems will be used to compile a report due to the LBB by December 1, 2012, profiling caregivers of consumers who are requesting Medicaid services through DADS or accessing caregiver services through AAAs.

Reductions of Community-based Interest Lists (Activities since 9/1/09)

Community Living Assistance and Support Services (CLASS) – 1,890 slots. As of 7/1/10, 1704 names have been released from the CLASS interest list to fill attrition and newly appointed slots.
Home and Community-Based Services (HCS) – 5,120 slots. As of 7/1/10, 3363 HCS offers have been released for interest list reduction and 2022 individuals have been enrolled.
Promoting Independence Initiatives – 620 total HCS slots: (1) 120 program vacancies for youth aging out of CPS conservatorship. As of 7/1/10, 60 HCS offers have been released and 54 individuals have been enrolled. (2) 250 for individuals in large ICF/MR facilities. As of 7/1/10, 113 offers have been made and 64 individuals have been enrolled. (3) 250 for residents of state supported living centers. As of 7/1/10, 186 slots have been released.
Prevention of Institutionalization – 196 HCS slots. Protocol for these slots has been approved and is in use by the MRAs. As of 7/1/10, 30 HCS offers have been released to individuals under the age of 18 years and 32 offers have been released for individuals over the age of 18 years.

Grants Initiatives

During the summer of 2009, staff assembled and convened the new Texas Respite Coalition (TRC) comprised of representatives from 35 agencies and organizations representing persons of all ages and disabilities and who are concerned about services for caregivers. The TRC advised and supported DADS’ Lifespan Respite Care Program grant application to the Administration on Aging (AoA).
In late September 2009, DADS was awarded $200,000 from AoA in support of the grant application to create a Texas Respite Coordination Center (TRCC). The TRCC has now been established and will conduct respite forums around the state, develop statewide resources, and support the efforts of the local entities working to increase respite services under H.B. 802.
Aging and Disability Resource Centers (ADRCs) are now operating in nine areas of Texas, including: Bexar County (San Antonio), Central Texas (five counties), Tarrant County (Fort Worth), Harris County, Lubbock County, five Counties in East Texas (Gregg, Harrison, Marion, Panola, Rusk and Upshur), four counties in North Central Texas (Collin, Denton, Hood, and Somervell), Dallas County, and El Paso/West Texas (six counties).
DADS plans to issue an RFP in fiscal year 2011 to establish two more ADRCs. Meanwhile, the DADS Commissioner has articulated his vision to have 20 ADRCs throughout Texas by 2020.
All the ADRCs now have common referral protocols and provide extensive training for community partners to facilitate referrals and service delivery.
The ADRCs are also working to enhance options counseling and support services by collaborating with hospital discharge planning departments to reduce hospital readmission and by providing additional structure to the operation of all ADRC projects for more uniformity of services.
DADS conducted a summit in June 2010 with all nine ADRCs and held it jointly with a site review from AoA and the national technical assistance contractor. At the summit DADS received federal guidance regarding the standardization of procedures and processes across all the ADRCs. The guidance was also used to apply for four new grant opportunities available from AoA in fall 2010. These new opportunities are related to: (1) ADRC project standardization, (2) the expansion of evidenced-based care transition activities in the Central Texas ADRCs, (3) coordination between ADRCs and MFP for a nursing home transition and diversion program, and (4) making ADRCs a focal point for assisting consumers in applying for the low-income subsidy for the Medicare Part D drug benefit.
In FY 2009, DADS established the Community Living Program (CLP), which is a partnership between DADS, the Central Texas ADRC and Scott & White Healthcare. The goal of the CLP was to establish a nursing home diversion program for individuals at imminent risk for nursing home placement and Medicaid spend-down. In summer 2010, the partners submitted a new grant application to the AoA to enhance this program in additional areas and hospitals in the Central Texas area and to expand the Care Transitions Intervention model and replicate it among the other ADRCs.
In FY 2010, DADS funded a second CLP, which will be a collaboration between DADS, the Area Agency on Aging of Tarrant County and the ADRC of Tarrant County. As with the CLP in Central Texas, this CLP is targeted to caregivers and older persons at imminent risk of nursing home placement and Medicaid spend-down.
DADS continues to expand its Texas Healthy Lifestyles (THL) Project. THL promotes chronic disease self-management and serves seniors who have at least one chronic condition. The program provides information about the risks associated with disease and the benefits of a healthy lifestyle.
The Communities Putting Prevention to Work Chronic Disease Self-Management Program (CDSMP) funded by the American Recovery and Reinvestment Act of 2009 through AoA awarded DADS $1 million to expand CDSMP. The Texas application was a collaborative effort between DADS Access and Intake Division, the Center for Policy and Innovation, and DSHS’ Adult Health and Chronic Disease Branch. DADS currently operates THL programs in Bexar County, Bryan-College Station and Houston. These new grant funds will expand the THL program to five additional areas of the state, and will include as lead partners area agencies on aging (AAAs) of Tarrant County, Rio Grande, Central Texas, Alamo Area and five AAAs working jointly throughout the east Texas region.
In March 2010, DADS received an additional $100,000 in continuation funds to support the ongoing efforts of CDSMP in the three original THL project areas (Bexar, Brazos Valley and Neighborhood Centers Inc, in Houston).
THL website: http://www.agingtexaswell.org/txhl/

Money Follows the Person (MFP) Demonstration (funded by CMS)

The MFP initiative helps people who reside in a nursing facility return to the community and receive long term services and supports without having to be placed on a community services interest list.

MFP website: http://www.dads.state.tx.us/providers/pi/mfp_demonstration/grantproposal/index.html

Other DADS Projects Supporting the Project Independence Plan

Realistic Job Preview Project: Agency staff have produced a 20 minute realistic job preview (RJP) video featuring direct support workers (DSWs) describing their jobs and speaking frankly about the rewards and challenges of working with individuals who have intellectual and developmental disabilities. Individuals and supervisors who hire direct support workers also appear in the video, describing the personal qualities that direct support work requires and the vital contributions that direct support workers make to individual lives. One hundred copies of the video have been provided to the Private Providers Association of Texas; other copies will be made available free of charge to individuals and employers who hire DSWs. The video will also be posted on the DADS website in the early fall of 2010. Editing of the second RJP video, focusing on working with individuals who are aging and/or who have physical disabilities, is now underway. This video will also be posted on the DADS website when completed. Both videos aim to reduce DSW turnover by educating job applicants about the rewards and challenges of the position prior to being hired.

Home and Community-Based Services Workforce Advisory Council: HHSC Executive Commissioner directed the creation of the Home and Community-Based Services (HCBS) Workforce Advisory Council (Council). The Council examined issues relating to recruitment and retention within the direct support workforce, including wages and benefits. The Council has provided the Executive Commissioner with its preliminary report which contains fifteen prioritized and actionable recommendations. A final version of the report will be delivered in November 2010. The Council membership was appointed by the Executive Commissioner and is made up of recipients and providers of direct care and support services, representatives of related associations, and mental retardation authorities. DADS, along with staff from HHSC, DARS and the Texas Workforce Commission, provides staff support to the Council.

Consumer Directed Services (CDS) Option Technical Assistance funded by CMS: Beginning 12/09, DADS and HHSC began working with Sue Flanagan, Ph.D., national expert on the Internal Revenue Service (IRS) rules for employer-agents. One of the key functions of a Consumer Directed Services Agency (CDSA) is to serve as the employer-agent with the IRS and Texas Workforce Commission (TWC) on behalf of the consumer/employer. Dr. Flanagan provided technical assistance to staff from Provider Services, the Center for Policy and Innovation, and HHSC-Medicaid policy in Austin on 12/8 – 12/9/09. Activities included:

Hosting a training session for CDSAs regarding the implementation of the IRS code for employer agents and upcoming changes to IRS policies related to tracking employer agents who file taxes on behalf of individuals who hire their own providers;
Developing a procedure for mid tax year transfers from one CDSA to another;
Setting up standards for CDSAs to obtain a contract with DADS and to continue to hold that contract; and
Meeting with Texas Mutual Insurance to explore purchasing worker’s compensation insurance for employees hired by consumers or their legally authorized representatives.

Supported Employment: Staff has continued working on DADS’ Employment Services Training and Technical Assistance Initiative. The purpose of the initiative is to improve employment outcomes for individuals with intellectual and developmental disabilities receiving services in DADS programs. As part of the initiative, staff hosted regional forums on employment for providers and other stakeholders. Forums were held in Fort. Worth (June 22), Houston (June 24), San Antonio (September 14) and Weslaco (September 16).

Another activity of the initiative, the Employment First pilot, began in April, 2010, with a voluntary group of state supported living centers and Home and Community-based Services waiver providers. Participants in the pilot will form a partnership locally with other organizations involved in employment services, and will utilize the resources and expertise of the partnership to assist at least three individuals interested in working to gain and maintain competitive, integrated employment. DADS will also offer sometimes next year, technical assistance grants for providers towards increasing the number of consumers in integrated, competitive employment.

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Updated: May 24, 2011