Transcript Document

TEXAS’ “STATE-SUPPORTED LIVING
CENTERS”: PAST, PRESENT, FUTURE
David Braddock, Ph.D.,
Associate Vice President, University of Colorado
Professor and Executive Director, Coleman Institute for Cognitive Disabilities
Federal Reserve Bank of Dallas
Austin, TX
September 14, 2011
Presentation © 2011 David Braddock
PRESENTATION
I. FROM INSTITUTIONS TO COMMUNITY
AND FAMILY SUPPORTS
II. THE IMPACT OF ECONOMIC
UNCERTAINTIES
III. DEVELOPMENTS IN TECHNOLOGY
APPLICATIONS IN DEVELOPMENTAL
DISABILITIES
2
I.THE INSTITUTIONAL ERA: 1403-1963
FIRST MENTAL DISABILITY INSTITUTIONS
BETHLEHEM, LONDON, ENGLAND (1403)
VALENCIA, SPAIN (1409)
ZARAGOZA (1425)
SEVILLE (1436)
VALLADOLID (1436)
PALMA MAJORCA (1456)
TOLEDO (1480)
GRANADA (1527)
SAN HIPOLITO (1566, Mexico City)
3
ABILENE EPILEPTIC COLONY,
ABILENE, TEXAS (1899)
D. Braddock, University of Colorado, 2007.
4
AUSTIN STATE SCHOOL (1917)
D. Braddock, University of Colorado, 2006.
5
NEW YORK STATE MENTAL RETARDATION
INSTITUTION, CIRCA 1967
Source: Braddock, D., University of Colorado, 2008.
6
DECLINING NUMBER OF INSTITUTIONAL RESIDENTS
WITH I/DD AND MENTAL ILLNESS IN THE U.S. (IN 1,000s)
700
Daily Census (Thousands)
600
Mental Illness
Intellectual/Developmental Disabilities
(1955)
559
500
400
300
(1967)
195
200
100
48,344
33,732
0
1844 1858 1872 1886 1900 1914 1928 1942 1956 1970 1984 1998 2009
Sources: Mental Illness Data-- U.S. Bureau of the Census, cited in Hamilton (1944); Center For Mental Health Services,
U. S. Department of Health and Human Services, 1996, 1999; NASMHPD, 2002, 2005
2007, 2008, 2009, 2010;
SAMHSA, 2003, 2005, 2006,
-- State of the States, Coleman Institute for Cognitive Disabilities and Department
Intellectual/Developmental Disabilities Data
of Psychiatry, University of Colorado, 2011.
7
II .TO COMMUNITY: KENNEDY & 88-164
8
TEXAS STATE PLAN (1966)
Source: Braddock, D., University of Colorado, 2008.
9
DECLINING I/DD STATE SCHOOL
UTILIZATION RATES: 1977-2009
Institutional Residentis per 100,000 Population
100
83
80
69
60
60
40
45
40
U.S.
Texas
31
20
29
23
23
22
22
16
14
13
20
11
0
77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09
Fiscal Year
Source: Braddock, D., State of the States in Developmental Disabilities, 2011.
10
TEXAS GENERAL POPULATION
INCREASES 125% FROM 1970-2010
30
General Population (Millions)
25.0
25
20.6
20
17.0
14.1
15
11.1
10
5
0
70 72 74 76 78 80 82 84 86 88 90 92 94 96 98 00 02 04 06 08 10
71 73 75 77 79 81 83 85 87 89 91 93 95 97 99 01 03 05 07 09
Fiscal Year
Source: U.S. Census Bureau (2011).
11
II.1 TRENDS IN I/DD SERVICES IN TEXAS
&THE U.S.
• Structure and Financing
of Intellectual/Developmental
Disability (I/DD) Services
12
STATE-OPERATED I/DD INSTITUTIONS IN TX
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Denton State School
Abilene State School
Mexia State School
Richmond State School
Lufkin State School
Austin State School
Brenham State School
Corpus Christi State School
State-operated ICF/ID
San Angelo State School
San Antonio State School
Lubbock State School
El Paso State Center
Rio Grande State Center
TOTAL
Source: Braddock, D., State of the States in Developmental Disabilities, 2011.
13
620
516
539
492
433
441
395
364
10
307
295
271
143
73
4,899
LARGEST CENSUS STATES, PER CAPITA*
CENSUS PER CAPITA*, 2009
1
2
3
4
5
6
7
8
9
10
Mississippi
Arkansas
New Jersey
Louisiana
Connecticut
Texas
North Dakota
North Carolina
South Dakota
Illinois
46.5
37.5
31.3
26.1
20.9
19.9
19.1
19.1
18.1
17.9
Source: Braddock, D., State of the States in Developmental Disabilities, 2011.
14
*Per 100,000 of the state
general population
INSTITUTIONAL PER DIEM RATES IN TEXAS
AND THE U.S.: 2009
TEXAS:
LOUISIANA
NEW MEXICO
U.S.:
Highest State (New York):
Lowest State (Arkansas):
$317*
$539*
$0*
$524
$1,237
$281
*Texas’ per diem ranked 3rd lowest of the 40 states with institutions,
Louisiana’s ranked 19th highest. New Mexico closed it’s last institution
(Los Lunas) in 1997.
Source: Braddock, D., State of the States in Developmental Disabilities, 2011.
15
STATES WITHOUT STATE-OPERATED
I/DD INSTITUTIONS
1. DISTRICT OF COLUMBIA (1991)
2. NEW HAMPSHIRE (1991)
3. VERMONT (1993)
4. RHODE ISLAND (1994)
5. ALASKA (1997)
6. NEW MEXICO (1997)
7. WEST VIRGINIA (1998)
8. HAWAII (1999)
9. MAINE (1999)
10. MICHIGAN (2009)
11. OREGON (2009)
12. ALABAMA (2012)
13. MINNESOTA (2000)*
14. INDIANA (2007)*
Source: Braddock, D., State of the States in Developmental Disabilities, 2011. *Denotes ICF/ID units in mental health institutions.
16
CUMULATIVE NUMBER OF COMPLETED/IN PROGRESS
CLOSURES OF STATE-OPERATED 16+ INSTITUTIONS, U.S.
175
153 154
Number of Closures
150
136
117
125
100
80
75
48
50
28
25
1
2
7
10
0
1969 1970 1975 1980 1985 1990 1995 2000 2005 2012 2013
Year
Source: Braddock, D., State of the States in Developmental Disabilities, 2011.
17
WHO’S NEXT?
SMALLEST INSTITUTIONAL
CENSUS, 2009
1 Nevada
48
2 Montana
64
3 Delaware
76
4 Wyoming
83
5 Idaho
96
6 Colorado
103
7 North Dakota
123
8 Arizona
126
9 South Dakota
146
10 Utah
236
Source: Braddock, D., State of the States in Developmental Disabilities, 2011.
18
WHO’S NOT?
LARGEST CENSUS, 2009
1 Texas
4,899
2 New Jersey
2,703
4 Illinois
2,308
3 California
2,194
5 North Carolina
1,638
6 New York
1,492
7 Ohio
1,423
8 Mississippi
1,371
9 Pennsylvania
1,253
10 Virginia
1,184
Source: Braddock, D., State of the States in Developmental Disabilities, 2011.
19
U.S. DEPARTMENT OF JUSTICE
REVIEWS TEXAS I/DD INSTITUTIONS
•
Justice Department in 2008 found poor care and little
protection from harm for Austin Center residents.
•
Austin Center now out of compliance with 153 of 171
provisions that were outlined in a June 2009 agreement.
•
Some improvements: increased staff pay, decreased staff
turnover, and new policies to protect residents.
•
However, half of the 350 Center residents have urgent dental
needs, patient restraint records are incomplete, and there are
continued employee problems.
•
Between November 2010 and May 2011 twelve staff were fired
for abuse or neglect of residents.
•
Disability activists say the State must close state centers,
move residents to community settings including group home.
A. Ball, American-Statesman, Austin, August 7, 2011.
20
INDIVIDUALS WITH I/DD IN OUT-OF-HOME
PLACEMENTS IN THE U.S., 2009
United States
Nursing facilities 16+
32,469
16+ Persons
Private 16+
16%
26,113
State inst.16+
33,732
7-15 Persons
58,136
33%
5%
4%
6%
Group, foster,
host homes,
apartments
196,211 Persons
6/Fewer Persons
75%
10%
42%
Supported Living
246,822 Persons
Total: 593,483 Persons
Utilization Rate: 194 per 100,000
Source: Braddock, D., State of the States in Developmental Disabilities, 2011.
21
INDIVIDUALS WITH I/DD IN OUT-OF-HOME
PLACEMENTS 33 YEARS LATER: 2009
TEXAS
14+ Persons (20% )
ICF/MR Group Homes - 5,029
Nursing Facilities - 2,880
11%
Other Group Homes 13,674
6%
State Schools - 4,899
31%
11%
Private ICF/MR 14+ - 1,374
9-13 Persons - 732 (2%)
<8 Persons (78% )
3%
36%
Supported Living - 16,194
Total: 44,782
Source: Braddock, D., State of the States in Developmental Disabilities, 2011.
22
Utilization Rate:
182 per 100,000
(32nd)
I/DD REVENUE SOURCES
IN 2009: UNITED STATES
Title XX/SSBG (1%)
STATE
$20.91 Billion
57%
FEDERAL
$30.58 Billion
39%
3%
LOCAL
$1.72 Billion
52%
HCBS Waiver
15%
Waiver SSI/ADC
25%
ICF/MR
6%
Other Medicaid
Other Federal (1%)
Total: $53.21 Billion
Source: Braddock, D., State of the States in Developmental Disabilities, 2011.
23
I/DD REVENUE SOURCES
IN 2009: TEXAS
38%
HCBS Waiver
13%
Waiver SSI/ADC
47%
ICF/MR
STATE
$593.7 Million
32%
66%
FEDERAL
$1,229.7 Million
LOCAL
$32.8 Million (2%)
Other Medicaid (1%)
Other Federal Funds (1%)
Total: $1.86 Billion
Source: Braddock, D., State of the States in Developmental Disabilities, 2011.
24
STATES VARY GREATLY IN THE
AMOUNT OF I/DD MEDICAID FUNDING
NY Times,
August 2, 2011
25
FEDERAL HCBS WAIVER SPENDING
DOUBLES ICF/ID SPENDING IN 2009
UNITED STATES
$20
Billions of 2009 Dollars
HCBS Waiver
$15.9
$15
$11.9
$9.4
$10
$10.1
$8.5
ICF/ID
$7.7
$7.9
$5
Intercept
(2001)
$0
73 75 77 79 81 83 85 87 89 91 93 95 97 99 01 03 05 07 09
Fiscal Year
Source: Braddock, D., State of the States in Developmental Disabilities, 2011.
26
BUT TEXAS’ WAIVER SPENDING IS
STILL BELOW ICF/ID SPENDING
TEXAS
$800
$702
$669
Millions of 2009 Dollars
$700
ICF/ID
$600
$584
$472
$500
$400
HCBS Waiver
$328
$338
$300
$228
$202
$200
$100
$46
$0
71 73 75 77 79 81 83 85 87 89 91 93 95 97 99 01 03 05 07 09
Fiscal Year
Source: Braddock, D., State of the States in Developmental Disabilities, 2011.
27
HCBS WAIVER PARTICIPANT GROWTH IS
INCREASING IN TEXAS: 1982-2009*
TEXAS
25,000
20,045
Number of Participants
20,000
18,619
16,433
14,455
15,000
12,447
10,204
9,111
7,955
7,123
10,000
4,601
5,000
2,398
5,140
3,164
1,335
0
0
0
68
288
420
82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09
Fiscal Year
Source: Braddock, D., State of the States in Developmental Disabilities, 2009. *Includes Home and CommunityBased Services (HCS) and Community Living Assistance and Support Services (CLASS) Waivers.
28
II.2: TEXAS HCBS WAIVER SERVICES
•
•
•
•
•
•
•
•
•
•
•
Case management; transition assistance;
Adaptive aids; minor home modifications;
Medical supplies; nursing;
Adult foster care; residential care and/or assistance;
Personal Emergency Response System (PERS)
OT, PT, Speech Pathology, Audiology; specialized therapies
Personal assistance;
Home delivered meals; dietary
Respite care;
Supported employment; day habilitation;
Dental, psychological services.
29
TEXAS HCBS WAIVER SERVICES (Cont.)
AMONG THE HCBS WAIVER SERVICES NOT PROVIDED:
• Assistive technology
• Community integration training
• Transportation
• Independent living skills training.
• Communication devices
• Nutritional counseling
• Private duty nursing
30
TEXAS “INTEREST LIST” FOR MEDICAID
WAIVER SERVICES AS OF MAY 2011*
• Texas has two major HCBS Waivers for
which persons with I/DD await services:
1. Home and Community Services (HCS)
Waiver: 51,856 persons on “interest list”
2. Community Living Assistance and
Support Services (CLASS) Waiver:
36,770 persons on “interest list”
Source: Texas Department of Aging and Disability Services (DADS) interest list.
*Duplicated Count. In March 2009, the HCS and CLASS “interest lists” were 41,011 and 25,289, respectively.
31
TEXAS RANKED 49th IN WAIVER UTILIZATION IN
2009, NEW MEXICO 8TH AND LOUISIANA 16TH*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
New York
$247
Maine
$230
Rhode Island
$214
Minnesota
$211
Vermont
$205
District of Columbia
$203
Wyoming
$178
New Mexico
$139
Connecticut
$133
Pennsylvania
$131
North Dakota
$131
West Virginia
$127
New Hampshire $124
Alaska
$124
Oregon
$121
Louisiana
$119
Arizona
$115
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
South Dakota
Wisconsin
Kansas
Delaware
Nebraska
Maryland
Tennessee
Iowa
Massachusetts
Hawaii
Michigan
Ohio
Washington
Montana
Indiana
Missouri
Colorado
$113
$106
$104
$100
$93
$91
$90
$89
$88
$82
$80
$79
$76
$72
$72
$66
$63
* Federal-State HCBS Waiver spending
per citizen of the general population.
Source: Braddock, D., State of the States in Developmental Disabilities, 2011.
32
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
Oklahoma
New Jersey
Virginia
Alabama
California
North Carolina
South Carolina
Florida
Utah
Arkansas
Idaho
Kentucky
Illinois
Georgia
Texas
Nevada
Mississippi
$63
$57
$56
$54
$52
$51
$51
$47
$47
$45
$44
$42
$38
$34
$28
$27
$13
UNITED STATES
$82
II.3 MEASURING COMMITMENT TO I/DD
SERVICES:FISCAL EFFORT & OTHER METRICS
Fiscal effort is a ratio that can be
utilized to rank states according to the
proportion of their total statewide
personal income devoted to the financing
of I/DD services.
Fiscal effort is defined as a state’s
spending for I/DD services per $1,000 of
total statewide personal income.
33
FISCAL EFFORT FOR I/DD SERVICES IN TEXAS LAGS
U.S. AVERAGE FOR 33 YEARS, DECLINED 2003-09
Dollars per $1,000 of Personal Income
$5.00
$4.25 $4.34
$4.02
U.S.
$4.00
$3.40
$3.00
TEXAS
$2.28
$2.30
$2.00
$2.03 $1.93
$1.00
(Texas ranked 50TH in 2009)
$0.00
77
79
78
81
80
83
82
85
84
87
86
89
88
91
90
93
92
95
94
97
96
Fiscal Year
Source: Braddock, D., State of the States in Developmental Disabilities, 2011.
34
99
98
01
00
03
02
05
04
07
06
09
08
LEADERS AND LAGGARDS IN
I/DD FISCAL EFFORT*: 2009
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
New York
$10.10
Maine
$8.32
Connecticut
$7.69
Minnesota
$7.54
North Dakota
$7.28
Louisiana
$7.13
Ohio
$6.84
Iowa
$6.50
Rhode Island
$6.31
Vermont
$6.21
District of Columbia $5.91
Pennsylvania
$5.70
West Virginia
$5.70
Wisconsin
$5.46
New Mexico
$5.34
Oregon
$5.18
Delaware
$5.00
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
Wyoming
Arkansas
Massachusetts
Idaho
South Dakota
Mississippi
Tennessee
Nebraska
Indiana
Kansas
North Carolina
Alaska
California
Michigan
New Hampshire
Montana
New Jersey
$4.90
$4.75
$4.72
$4.69
$4.59
$4.26
$4.17
$4.16
$4.13
$4.11
$4.06
$3.95
$3.82
$3.80
$3.79
$3.77
$3.62
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
South Carolina
Arizona
Missouri
Washington
Oklahoma
Illinois
Hawaii
Utah
Maryland
Kentucky
Virginia
Alabama
Colorado
Georgia
Florida
Texas
Nevada
UNITED STATES: $4.34
*Fiscal effort is I/DD spending per $1,000 of statewide aggregate personal income.
(LOUISIANA 6TH, NEW MEXICO 15TH AND TEXAS 50TH)
Source: Braddock, D., State of the States in Developmental Disabilities, 2011.
35
$3.49
$3.49
$3.45
$3.42
$3.39
$3.13
$3.11
$2.94
$2.89
$2.87
$2.73
$2.28
$2.23
$2.14
$2.09
$1.93
$1.59
STATES RANKED BY PERSONAL INCOME PER
CAPITA, 20101
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
1
District of Columbia
Connecticut
Massachusetts
New Jersey
Maryland
New York
Wyoming
Virginia
Alaska
New Hampshire
Washington State
Illinois
California
Minnesota
Colorado
Rhode Island
Pennsylvania
Hawaii
North Dakota
Vermont
Delaware
Kansas
Nebraska
TEXAS
Florida
South Dakota
$71,044
$56,001
$51,552
$50,781
$49,025
$48,821
$47,851
$44,762
$44,174
$44,084
$43,564
$43,159
$43,104
$42,843
$42,802
$42,579
$41,152
$41,021
$40,596
$40,283
$39,962
$39,737
$39,557
$39,493
$39,272
$38,865
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
LOUISIANA
Wisconsin
Iowa
Maine
Oregon
Nevada
Missouri
Oklahoma
Ohio
North Carolina
Michigan
Georgia
Montana
Tennessee
Arizona
Indiana
Alabama
NEW MEXICO
Kentucky
South Carolina
Arkansas
West Virginia
Utah
Idaho
Mississippi
UNITED STATES
$38,446
$38,432
$38,281
$37,300
$37,095
$36,997
$36,979
$36,421
$36,395
$35,638
$35,597
$35,490
$35,317
$35,307
$34,999
$34,943
$33,945
$33,837
$33,348
$33,163
$33,150
$32,641
$32,595
$32,257
$31,186
$40,584
District of Columbia not ranked by Bureau.
Sources: Estimates for 2010 based on 4/1/10 decennial census data (released 12/10); U.S.
Bureau of Economic Analysis and Bureau of the
36Census (2011).
III.RECENT TRENDS IN: Family Support,
Supported Employment,& Aging Caregivers
1. FAMILY SUPPORT
2. SUPPORTED
EMPLOYMENT
3. IMPACT OF AGING
CAREGIVERS
37
III.1: FAMILY SUPPORT DEFINED
FAMILY SUPPORT INCLUDES
•
Respite
•
Family counseling
•
Architectural adaptation of the home
•
In-home training, education, behavior management
•
Sibling support programs, and
•
Purchase of specialized equipment
“CASH SUBSIDY FAMILY SUPPORT” INCLUDES:
Payments or vouchers directly to families;
families determine what is purchased
38
FAMILIES SUPPORTED IN TEXAS ARE 12% OF
TOTAL ESTIMATED I/DD CAREGIVING FAMILIES
300.0
Total I/DD Caregiving Families
Families Supported by State I/DD Agencies
THOUSANDS OF FAMILIES
250.0
220.3
228.4
234.1
9%
12%
201.0
200.0
150.0
100.0
50.0
0.0
5%
5%
99
00
01
02
03
04
05
FISCAL YEAR
Source: Braddock, D., State of the States in Developmental Disabilities, 2011.
39
06
07
08
09
FAMILIES SUPPORTED: TEXAS LAGS
THE U.S. AVERAGE
Families
Supported
% of All
Caregiving National
Families
Rank
33%
3
26%
10
17%
12%
31
State
New Mexico
Louisiana
UNITED STATES
Texas
Source: Braddock, D., State of the States in Developmental Disabilities, 2011.
40
III.2: SUPPORTED EMPLOYMENT
“While supported employment
has made significant gains since its
formal introduction in 1984 (P.L. 98527), segregated services continue
to outpace the growth of supported
employment nationally.”
True in 2004 and true today.
(Rusch & Braddock, Research and Practice for Persons with Severe Disabilities, 2004)
41
PER CAPITA* SUPPORTED EMPLOYMENT
WORKERS IN LOUISIANA AND TEXAS LAST IN U.S.
*Per 100,000 of
General Population
National
Rank
1
2
3
4
5
6
7
8
9
10
13
49
50
Workers per
Capita
(General
State
Population)
Vermont
146
Connecticut
129
Iowa
111
Oklahoma
93
South Dakota
90
Maine
87
Maryland
82
Pennsylvania
75
Alaska
71
District of Columbia
71
New Mexico
63
Texas
3
Louisiana
2
UNITED STATES
34
42
III.3: IMPACT OF
AGING
CAREGIVERS
43
LONGEVITY INCREASES FOR PERSONS WITH
AN INTELLECTUAL DISABILITY
• 1970s: 59.1 years
• 1993: 66.2 years
• U.S. General Population: 70.4 years
• In the future “…those without severe
impairment can be expected to have a life
span equal to that of the general
population.”
Source: M. Janicki. (1996). Rehabilitation Research and Training Center on Aging and Mental Retardation,
University of Illinois at Chicago.
44
20% OF PERSONS WITH I/DD LIVE AT HOME WITH
CAREGIVERS AGED 60 YEARS OR MORE
TEXAS
AGING CAREGIVERS AGED 60+
46,752
Caregivers Aged <41
105,224
20%
45%
35%
Caregivers Aged 41-59
82,121
TOTAL FAMILY CAREGIVERS: 234,097
Source:Braddock et al., Coleman Institute and Department of Psychiatry, University of Colorado, 2011,
based on Fujiura (1998).
45
STATES WITH GREATEST AND LEAST PROPORTIONS
OF RESIDENTS AGED 65+ YEARS, ‘09
FLORIDA (1st)
17.2%
WEST VIRGINIA (2nd)
15.8%
MAINE (3rd)
15.6%
PENNSYLVANIA (4th)
15.4%
IOWA (5th)
14.8%
U.S.
12.9%
COLORADO (47th)
10.6%
GEORGIA (48th)
10.3%
TEXAS (49th)
10.2%
UTAH (50th)
9.0%
ALASKA (51st)
New Mexico 32nd
and Louisiana 38th
0%
5%
10%
15%
20%
25%
PERCENT OF STATE POPULATION AGED 65+
Source: U.S. Bureau of the Census, 2010
46
AGING POPULATION DOUBLES 2010-40, U.S.
AGED 65+ YEARS: 2010-2050
100
Americans Aged 65+ (Millions)
87
80
80
71
60
55
40
40
20
0
2010
2020
2030
Year
Source: U.S. Bureau of the Census, 2009
47
2040
2050
III.4: ECONOMIC
UNCERTAINTY
IN THE STATES
48
ONLY THE DISTRICT OF COLUMBIA IS
CONFIDENT ABOUT THE U.S. ECONOMY
ECONOMIC CONFIDENCE INDEX
Least Pessimistic
Most Pessimistic
DISTRICT OF COLUMBIA
Nebraska
North Dakota
South Dakota
Maryland
Massachusetts
Utah
Iowa
Minnesota
Virginia
Alaska
Colorado
Wisconsin
Texas
California
Hawaii
South Carolina
Georgia
Kansas
New York
Illinois
New Hampshire
New Jersey
Pennsylvania
North Carolina
Washington
New Mexico
Connecticut
Vermont
Indiana
Alabama
Missouri
Michigan
Oklahoma
Arizona
Montana
Wyoming
Arkansas
Oregon
Tennessee
Rhode Island
Florida
Ohio
Delaware
Kentucky
Nevada
Mississippi
Louisiana
Idaho
Maine
West Virginia
11
-13
-16
-17
-17
-19
-19
-20
-20
-20
-22
-24
-25
-26
-26
-26
-27
-27
-27
-28
-28
-28
-29
-29
-29
-30
-30
-30
-31
-31
-31
-31
-31
-31
-33
-33
-33
-33
-33
-33
-34
-34
-34
-35
-35
-35
-36
-37
-37
-39
-44
-45 -40 -35 -30 -25 -20 -15 -10 -5
49
0
5 10 15
Gallup Poll, in C.
Rampell, "Why
Washington
Likes Itself," NY
Times, 8/28/11
INDEX OF ECONOMIC MOMENTUM 1 IN THE STATES:
JUNE 2011
U.S.
RANK
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
STATE
North Dakota
Texas
Oklahoma
Nebraska
South Dakota
Utah
Alaska
Wyoming
Colorado
Wisconsin
Washington State
Louisiana
Illinois
Idaho
Oregon
Vermont
Virginia
Montana
Delaware
Massachusetts
Kansas
Iowa
California
Minnesota
Kentucky
Ohio
INDEX
4.68
1.29
1.08
0.91
0.75
0.75
0.70
0.69
0.36
0.26
0.23
0.19
0.18
0.15
0.14
0.13
U.S.
RANK
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
0.08
0.07
0.06
0.06
0.05
0.04
0.04
0.03
0.03
0.01
43
44
45
46
47
48
49
50
51
Missouri
Indiana
Alabama
Georgia
Maryland
New York
Maine
Nevada
New Jersey
UNITED STATES
1
Weighted average growth in personal income,
employment and population (Federal Funds
Information for States, June 2011).
STATE
INDEX
Arkansas
0.00
Michigan
-0.03
Arizona
-0.08
Hawaii
-0.08
Pennsylvania
-0.11
New Mexico
-0.12
Rhode Island
-0.12
District of Columbia-0.13
Connecticut
-0.13
Tennessee
-0.13
New Hampshire
-0.19
South Carolina
-0.24
West Virginia
-0.25
Florida
-0.29
North Carolina
-0.33
Mississippi
-0.38
50
-0.41
-0.42
-0.49
-0.51
-0.52
-0.58
-0.76
-0.92
-1.02
0.00
CHANGING POPULATION MIGRATION
IN THE STATES 2006-09
OUT-MIGRATION: TOP 5 STATES
California
(793,578)
New York
(639,918)
Michigan
(356,139)
New Jersey
(229,605)
Illinois
(229,524)
IN-MIGRATION: TOP 5 STATES
Texas
644,310
North Carolina
373,278
Arizona
298,480
Georgia
298,235
South Carolina
183,159
Source: Federal Funds Information for States (2009). State Policy Reports, Vol. 27, No. 21.
51
7th Louisiana
(184,145)
20th New Mexico
21,712
STATE BOND RATINGS: AUGUST 2011
TIER 1
Delaware
Florida
Georgia
Indiana
Iowa
Maryland
Minnesota
Missouri
Nebraska
North Carolina
Utah
Virginia
Wyoming
TIER 2
AAA
AAA
AAA
AAA
AAA
AAA
AAA
AAA
AAA
AAA
AAA
AAA
AAA
Alaska
Idaho
Kansas
New Mexico
North Dakota
Ohio
Oklahoma
Oregon
South Carolina
South Dakota
Tennessee
Texas
Vermont
Washington
TIER 3
AA+
AA+
AA+
AA+
AA+
AA+
AA+
AA+
AA+
AA+
AA+
AA+
AA+
AA+
Alabama
Arkansas
Colorado
Connecticut
Hawaii
Louisiana
Maine
Massachusetts
Mississippi
Montana
Nevada
New Hampshire
New York
Pennsylvania
Rhode Island
West Virginia
Wisconsin
TIER 4
AA
AA
AA
AA
AA
AA
AA
AA
AA
AA
AA
AA
AA
AA
AA
AA
AA
Source: Standard & Poor's Ratings, August 11, 2011
Up in rank since January 2010: ID, LA, NE, OR, SD, & OR; down in rank: NV, NJ.
52
Arizona
Kentucky
Michigan
New Jersey
AAAAAAAA-
TIER 5
Illinois
California
A+
A-
SELECTED
SOVEREIGN
NATIONS
Canada
France
Germany
Sweden
United Kingdom
USA
Chile
Spain
China
Japan
Italy
Ireland
Russia
India
Portugal
Greece
Libya
AAA
AAA
AAA
AAA
AAA
AA+
AA
AA
AAAAA+
BBB+
BBB+
BBBBBBCC
NR
(August 11, 2011; NR - No rating)
IV. DEVELOPMENTS IN TECHNOLOGY
1. GENERAL ADVANCES
2. SMART HOME
TECHNOLOGIES
3. PERSONAL SUPPORT
TECHNOLOGIES
4. CLOUD COMPUTING
53
IV.1 GENERAL ADVANCES IN
TECHNOLOGY
THE ARC’s PROPHECY: 22 YEARS AGO
There is a prevailing belief …in the field of assistive
technology that people with mental retardation are not
appropriate consumers of assistive technology…
People with mental retardation should be named as a
‘traditionally underrepresented group’…It is the belief
of the Association for Retarded Citizens of the United
States that advances [in AT] will not occur without
strong leadership from our federal government
(Cavalier, 1988)
Source: Testimony of A. Cavalier before the Senate
Subcommittee on the Handicapped, 1988.
54
ADVANCES IN MICROELECTRONICS

Dramatic increase in price-performance of
computing technology

Advances in wireless technology, GPS,
broadband, and web-based services

Improved access to computers & the Internet
including voice recognition systems

Easier to use Personal Digital Assistants (PDA’s)
with “prompting capabilities” and “contextawareness”
Source: D. Braddock, State of the Science Conference, Denver, 2006.
55
A NEW GENERATION OF TECHNOLOGIES
AS SOME
MARKETS
MATURE…
NEW HIGHGROWTH
MARKETS
EMERGE…
Sources: Adapted from Business Week, August 25, 2003.
56
IV.2: DOWN TO EARTH:
SMART HOME TECHNOLOGY
“I think we can do a ‘virtual nursing
home’ with technology”…
Andy Grove
Co-Founder, Intel Corp.
In USA Today, 2006
57
U.S. DEMAND FOR ID RESIDENTIAL
SERVICES IN THE NEXT DECADE IS 165,000
UNITED STATES
Thousands of Persons
900.0
6 or Fewer Person Settings
7-15 Person Settings
Public and Private 16 + Person Settings
772.7
607.1
600.0
440.2
345.2
300.0
0.0
259.9
1980
1990
2000
Fiscal Year
Source: Braddock, D., State of the States in Developmental Disabilities, 2011.
58
2010
2020
Projected from 2000-2009
I/DD RESIDENTIAL SERVICES EXPECTED
TO GROW BY 31,000 PERSONS 2010-2020
Thousands of Persons
100
80
TEXAS
6 or Fewer Person Settings
7-15 Person Settings
Public and Private 16 + Person Settings
76.7
60
45.9
40
20
0
19.9
16.0
10.2
1980
1990
2000
Fiscal Year
Source: Braddock, D., State of the States in Developmental Disabilities, 2011.
59
2010
2020
Projected from 2000-2009
INTEGRATED WIRELESS
SENSOR NETWORKS
IN THE FUTURE:
 A combination of wireless cell phone,
Internet, and sensor technology will
connect people, objects, and events.
 Smart homes/care will play key roles in
assisted living for persons with I/DD,
allowing seamless connectivity between
clients, caregivers/health care providers,
and parents.
60
WHERE TO PUT WIRELESS SENSORS?
TWO PRIMARY METHODS TO REMOTELY MONITOR A
PERSON’S PHYSICAL AND MENTAL STATE AND
LOCATION:
1. Via instrumenting the environment
(Sensors located in rooms, on doorways, drawers,
faucets, light switches, mattresses, pill bottles, etc.)
2. Via sensors located directly on people
Both have advantages: environmental sensors are less
instrusive, and do not require user compliance.
Person sensors offer more direct measurement.
61
MIT PLACELAB - BEHIND THE SCENES
Context-aware PDA with wireless
sensors/motes
Source: MIT PlaceLab website at http://architecture.mit.edu/house_n/placelab.html
62
U.S. SMART HOME SERVICE
PROVIDERS FOR PERSONS WITH ID
• IMAGINE!
BOULDER AND LONGMONT,
COLORADO
• REST ASSURED, LLC.,
LAFAYETTE, INDIANA
• SOUND RESPONSE,
MADISON, WISCONSIN
Source: Braddock, D., Coleman Institute, University of Colorado, 2010.
63
IMAGINE! SMART HOME, BOULDER,
COLORADO: COMPLETED 2009
Imagine! Smart Homes in Boulder and Longmont, Colorado
http://www.imaginesmarthomes.org/
64
IMAGINE! SMART HOME, BOULDER,
COLORADO: GREEN TECHNOLOGIES
Photovoltaic cells
generate electricity
Geothermal systems heat
and cool the home
65
IMAGINE! SMART HOME, LONGMONT, CO,
OPENED MAY 2011
Imagine! Smart Homes in Boulder and Longmont, Colorado
http://www.imaginesmarthomes.org/
66
FUNDING FOR HOMES
• Private donations
• HUD
• Cities of Boulder and
Longmont
• State of Colorado/Medicaid
67
IMAGINE! SMART HOMES,
BOULDER/LONGMONT
STAFF SYSTEMS
•
•
•
•
•
•
Employee/manager portal for centralized
information collection and reporting
Web-based medication prompt system
Location based activity prompting/logging
Web based training courses
Lifelogging of resident histories
Family portal for daily activities and health
status with text and picture-sharing
68
IMAGINE! SMART HOMES,
BOULDER/LONGMONT
CONSUMER, ENVIRONMENTAL AND
COMMUNICATIONS ADAPTATIONS
•
•
•
•
•
•
Accessible control of environment and appliances
Accessible, safe kitchen and bathroom
Cameras monitor high-risk areas
Automated windows and doors
Task prompters and reminders
Specialized, accessible PC, Internet, journaling
and web conferencing
69
IMAGINE! SMART HOMES,
BOULDER/LONGMONT
ELITE CARE/CUROTEK WEBBASED MONITORING SYSTEM
• Activity and safety sensors are
utilized: bio-metric, motion, pressure,
contact, security, fire, temp, nurse
call, door threshold.
• Residents’ badges provide location,
call for assistance.
• Real-time resident monitoring, alerts,
reporting and care planning.
70
IMAGINE! SMART HOME ADAPTS ELITE
CARE WEB-BASED MONITORING SYSTEM
71
Elite Care Technologies CARE Systems
Creating Autonomy-Risk Equilibrium
•
•
•
•
•
•
•
•
Infrared/RF tracking
Pendant Assistance calls
Bed weight, threshold, motion
Control lights, locks, appliances
Programmable events/alerts
Building sensors/controls
Real-time Intra/Intranet
DB Reports, trends, queries
Holistic care model
Open building design
Supportive technology
Oregon Assisted Living
Oatfield Estates
Jefferson Manor
www.elitecare.com
72
SMART HOUSE BADGE
Assist resident
 Badge detects when resident
reaches his/her room
 Unlock their doors
 Turn lights on/off
 Turn ceiling fan on/off
 Disable unsafe appliances
Predict/prompt activity (future)
 Using statistical
modeling
Elite
Source: Elite Care Corp.
CARE
Copyright 2001
73
REST ASSURED PROGRAM
Staff person monitors several apartments simultaneously.
74
REST ASSURED PROGRAM
• Uses PTZ (Pan, Tilt, Zoom) cameras for monitoring
in high risk areas like the kitchen
• Remote supervision via two-way audio/video
communication with caregiver
• Motion, temperature, carbon monoxide, and door brake
sensors used in, in addition to a Personal Emergency
Response System
• Consumers report increased independence; caregiver
is not a constant physical presence in the house
• Reduced overall cost of care
• Currently used primarily for third-shift support
Source: Rest Assured, Wabash, Indiana.
75
REST ASSURED PROGRAM–ATTRIBUTES
• Developed in collaboration with EPICS
(Engineering Projects In Community
Service) at Purdue University
• Serves consumers with ID
• Nearly 300 homes and apartments with
over 400 consumers served in eight states:
FL, GA, IL, IN, KS, MD, OH, & WI
• Recent agreement with Humana to market
technology to 500,000 elderly caregivers
Source: Dustin Wright, General Manager, Rest Assured, LLC, Wabash, Indiana.
76
SOUND RESPONSE SYSTEMS: MADISON
• Professional Monitors
• Communication between
Monitor and staff/
individuals served
• Access to protocols and
personal intervention
strategies
• Provider agency back-up
• Individualized alarm
readings
• Generates reports
77
SENSORS









Personal Pagers
Door/Window Security Sensors
Smoke Detectors
Carbon Monoxide Detectors
Flood/Moisture Sensors
Motion/Sound Sensors
Stove Sensors
Incontinent Detectors
Other Sensors Available Upon Request
78
EQUIPMENT FEATURES
 Completely Wireless in the Home
 Cellular Transmission- No Phone or Internet
Connection is Required
 2-Way Communication
 Event Sequencing
 Data Tracking
 Portable and Adaptable to People’s
Homes and Abilities
Sound Response costs average between
$25 to $850 per person per month
79
INDIANA GOVERNOR MITCH DANIELS
ENDORSES SMART HOME TECHNOLOGY
“We can alleviate some of the demand for Direct
Support Professionals (DSPs) by identifying
new service options for people who do not
need intensive DSP support.
The system is tailored to the needs of each
person who uses it and has been shown to
improve personal independence, as well as
alleviating the needs for a direct support
professional where one is not needed.”
Mitch Daniels, Governor, State of Indiana
The Arc of Indiana, Meet the Candidates, Summer 2008
80
STATES WITH MEDICAID SUPPORT
FOR SMART HOME TECHNOLOGIES
CURRENTLY HAS MEDICAID WAIVER
AMENDMENT APPROVED BY CMS
• INDIANA, KANSAS, LOUISIANA, OHIO, &
WEST VIRGINIA
SELF-DIRECTED WAIVER ALLOWING FOR
TECHNOLOGIES
• WISCONSIN
STATES EXPRESSING INTEREST IN
SUBMITTING WAIVER AMENDMENTS FOR
TECHNOLOGIES TO CMS
• KENTUCKY, MASSACHUSETTS,
& NEW JERSEY
81
EVOLUTION OF SMART HOME
TECHNOLOGY
Care information systems … on web
2000
Predictive modeling
Cognitive Assistance
2015
2005
We are here
RECOMMENDATIONS:
o Adopt early: learn from experience
o Start small: expand incrementally
o Adopt gradually: change care procedures
o Assess needs, cost-benefits, & risk
o Plan pilot & evaluation with R&D partner
o
Source: Rodney Bell, Coleman Institute consultant (2007)
82
2020
II.3: PERSONAL SUPPORT TECHNOLOGIES
1. PDA Task Prompting Software
2. Adapted Web Browser
3. Adapted E-mail
4. Audio Books
5. Location Tracking
6. Personal Support Robots,
Teaching Technologies
83
PDA TASK PROMPTING SOFTWARE
Visual Assistant (Prompting System)
Source: Ablelink Technologies, Colorado Springs (Terry & Jonathan).
84
VISUAL ASSISTANT
 A pocket personal computer with an
integrated PC-slot digital camera;
 Staff/caretakers take pictures of—
and narrate--the steps in a task;
 The verbal instructions and images
guide users through the steps:
– Grocery shopping
– Medications
– Personal hygiene
– Using public transportation, etc.
SOURCE: Ablelink Technologies, Colorado Springs.
85
ADAPTED WEB BROWSER AND E-MAIL
Adapted Web Browser
Adapted E-mail Program
The Web Trek adapted web
browser improves access to the
World Wide Web for people who
have difficulty with reading and
writing.
SOURCE: Ablelink Technologies, Colorado Springs.
86
ROCKET READER AUDIO BOOKS
Source: Ablelink Technologies, Colorado Springs; www.ablelinktech.com
87
LOCATION TRACKING
Nextel mobile locator:
http://www.nextel.com/en/services/gps/mobile_locator
 Wherifone:
http://www.wherify.com/wherifone/
Accutracking:
http://www.accutracking.com/
911 to go:
http://www.travelbygps.com/articles/tracking.php/
Contact your cell phone provider for phones/services
88
TREKKER BREEZE GPS
Verbally announces the
names of streets,
intersections and
landmarks as you walk.
Source:
http://www.visabilitystore.or
g/browse.cfm/trekkerbreeze-gps/
89
INDOOR WAYFINDING SUPPORT
Participants
preferred images
with arrows, not
audio alone
SOURCE: http://cognitivetech.washington.edu/assets2006_liu.pdf.
90
[In Development]
PERSONAL SUPPORT ROBOTS
Can serve as “life support partner” to follow a person from
place to place, respond to commands, aid in activities of daily
living, help with route finding, interact with others.
Source: Maja J Mataric, University of Southern California, Viterbi School of Engineering
91
TEACHING TECHNOLOGIES
Animated Teaching/Learning Tools
 Students choose animated images representing
themselves and their teacher.
 Then students use the animated characters to engage
in learning activities such as reading instruction.
 Each of the 7 characters
makes hundreds of
emotions and
expressions in real time.
For more information contact Sarel Van Vuuren at [email protected]
http://ics.colorado.edu/
92
COGNITIVE ASSISTANCE FRONTIER
• Envisions systems with wearable or
environmental sensors that infer a user’s
context and cognitive state.
• Prompts, reminders, and other forms of
automatic intervention.
• Tasks addressed include navigation,
remediation of memory impairments,
behavioral self-regulation, and monitoring
and guidance in the performance of ADLs.
Henry Kautz
Department of Computer Science
University of Rochester, January 2010
93
Coleman Institute Conference,
October 13, 2011 in Westminster, CO
State of the States, State of the Nation: 2011
PETER BLANCK, PhD, JD, Chairman, Burton Blatt Institute, Syracuse University
DAVID BRADDOCK, PhD, Chair of Conference, Associate VP, University of Colorado
ANN CALDWELL, PhD, Chief Research and Innovations Officer, The Arc of the US
HENRY CLAYPOOL, Director, Office on Disability, US DHHS
BILL COLEMAN, founding donor, partner, Alsop-Louie Partners, San Francisco
DIANE COYLE, PhD, economist, internationally acclaimed author of The Economics of
Enough: How to Run an Economy as if the Future Matters, Princeton Univ. Press
MARK EMERY, CEO, Imagine! Colorado
JIM GARDNER, PhD, President and CEO, The Council on Quality and Leadership
SHARON LEWIS, Commissioner, Administration on Developmental Disabilities, US
Department of Health and Human Services (USDHHS)
WILLIAM POUND, Executive Director, National Conference of State Legislatures
JO ANN SIMMONS, Board Chair, National Down Syndrome Society
SUE SWENSON, Deputy Assist. Secretary for Special Education and Rehabilitation
NANCY THALER, Executive Director, National Association of State Directors of
Developmental Disabilities Services (NASDDDS)
ColemanInstitute.org
94
CONTACT INFORMATION
David Braddock, Ph.D.
Coleman-Turner Professor of Psychiatry
& Executive Director
Coleman Institute for Cognitive Disabilities
University of Colorado System (SYS 586)
3825 Iris Avenue, Suite 200
Boulder, CO 80301
E-mail: [email protected]
Phone: 303-492-0639
http://ColemanInstitute.org
95