Transcript Slide 1
CIL-NET Presents…
Implementing and Enforcing Olmstead A National Onsite Training
The California IL Approach to Olmstead May 11, 2011 Atlanta, Georgia Presenter: Laurel Mildred California Foundation for Independent Living Centers (CFILC) CIL-NET, a project of ILRU – Independent Living Research Utilization 1
Who We Are
• Based in our state capitol of Sacramento, the California Foundation for Independent Living Centers is a statewide, non-profit trade organization representing 24 Independent Living Centers.
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CFILC
• The mission of the California Foundation for Independent Living Centers is to advocate for barrier-free access and equal opportunity for people with disabilities to participate in community life by increasing the capacity of Independent Living Centers to achieve their missions.
• The statewide approach has resulted in strengths in public policy, organizing and technological innovation.
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Topics
I.
CFILC’s Olmstead Project II.
Our 2010 “Olmstead Summit” III.
Key Policy Work
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I. Our Olmstead Project
Background
After receiving ILC community input, the State Independent Living Council and the California Department of Rehabilitation made Olmstead implementation a priority, and designed several grant opportunities intended to advance implementation using American Recovery and Reinvestment Act (ARRA) funds.
One of these projects emphasized public policy.
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Funded Through ARRA
• In 2009, CFILC applied for and was awarded the public policy grant from our state Department of Rehabilitation. It is a two-year project.
• Our proposal was to re-start a defunct Olmstead Coalition, and to bring policy and training resources to ILCs and other advocates in order to strengthen their capacity to move Olmstead forward.
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Californians for Olmstead
We called our project CALIFORNIANS FOR OLMSTEAD.
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Mission Statement
• The mission of Californians for Olmstead is to work toward community inclusion of all people with disabilities in California through the implementation of the Olmstead decision. We do this by working with people with disabilities to secure public resources and quality support needed for people to live full and equal lives in the community.
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Broad Strategies
• • • Coalition Building: The Project provides a context for ILCs to work with other organizations, such as aging, disease-specific, and poverty and civil rights advocates.
Deepen Policy Focus: The Project has provided in depth focus on key issues, and informs and supports the ILC “Systems Change Network” as well as Coalition partners.
Coordination with Transition Services: The Project connects with ILC’s in their role as transition services providers, bringing their hands-on experience into policy advocacy.
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Major Project Activities
• • • • • • Develop Communications Structure, Website, Facebook Page, Listserv Revitalize Olmstead Coalition Hold Monthly Teleconference Meetings Achieve Public Policy Outcomes (4-6 positive and 4-6 defensive) Take Advocacy Action and Develop Toolkits Organize a Series of Trainings
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Our Initial Assessment of Barriers
• • • Lack of specificity and accountability in California’s Olmstead Plan.
Lack of a “system” in the long term care system, characterized by fragmentation of services and funding, with implications for the individual consumers and the overall budgets for services.
Policymakers’ acknowledgement of the effectiveness of the In Home Supportive Services (IHSS) program in reducing dependence on nursing home services, juxtaposed with policymakers reduction in funding for IHSS.
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Our Initial Assessment of Barriers, cont’d.
• • • Small federally-funded pilot programs, but no overall commitment to expanding those programs to other areas or other populations.
Huge increases in spending for nursing homes, whose funding is separate from home and community-based services.
Lack of legislative knowledge and leadership on Olmstead and community integration, as compared to legislative mandates in other states.
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Our Initial Assessment of Barriers, cont’d. 2
• • Duplicative use of assessments for long term care users and lack of true care management for those who want it.
Lack of affordable, accessible housing as a major barrier to community integration, with no coordinated effort to overcome this barrier.
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Situational Analysis: All Budget, All the Time
• California’s ever worsening budget problems have put advocates on constant defense over a period of years. • Cuts have impacted all services in the community system of care, and taken together, the UCLA Center for Health Policy estimated that the proposals “turn back the clock 30 years” on California’s long-term care system. Some of these cuts have been defeated, others have become the new normal.
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And It’s Not Over Yet
• • • This year Governor Jerry Brown proposed, and the Legislature has adopted, $12.5 billion dollars in statewide program cuts (to all programs and services). Balancing our budget now requires $12.5 billion from extending current temporary taxes that are set to expire.
The revenue piece has precipitated a large political battle.
Without resolution, California faces an “All Cuts” budget of an additional $12.5 Billion in reductions.
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And It’s Not Over Yet, cont’d.
• A key challenge of the Project has been to stay active and relevant on fighting devastating cuts while holding the space for a longer-term vision of system change.
• We tried to bring valuable budget resources to support advocacy, stay involved in the key long term system change issues, and set careful priorities for issues to go into in more depth.
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How We Set Policy Priorities
• • • • • Foremost Consideration – Achieving Grant Deliverables Organizational Priorities – CFILC ED Coordinated Work with Systems Change Network and Other ILC Projects Expressed Concerns of ILC Directors Expressed Concerns of Coalition Members Project Manager’s Experience – Discretion to Pursue Critical Policy Issues
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Our Training Series
These will be live, interactive, accessible webinars (Elluminate training platform)
1.
Critical Issues in Olmstead Implementation
Overview, Policy Framework and Review of Litigation
2.
There's No Place Like Home
The HUD HOME Investment Partnership Presents an Opportunity to Support Housing for People Transitioning From Institutions – with Steve Gold
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Our Training Series, cont’d.
3.
The Game-Changing Strategy
Building an Effective System of Long-term Services and Supports through Implementation of the Federal Affordable Care Act
4.
Follow the Money
Using Cost-Effectiveness in Advocacy for Long-term Services and Supports
5.
Getting the Message Out
Enhancing Advocacy Through Effective Communication about Olmstead
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Final Project Outcome
• Our final deliverable, due in September, is a blueprint for future action.
• This report will be posted on our website.
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II. California Olmstead Summit
• Our Major Year-One Project was to Convene Disability Community Leaders and Advocates from Around the State Around Issues of Olmstead Implementation • We Planned, Collaborated and Shared Costs with our Protection and Advocacy Organization, Disability Rights California
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II. California Olmstead Summit, cont’d.
• In September of 2010, 50 Key Leaders Gathered from Around the State to Hear a Keynote from the Department of Justice and Participate in the Summit.
• Day 1 Included 4 Policy Panels Featuring State and National Experts • Day 2 Included a Training in Communications by Public Works; the DEMOS Center for the Public Sector
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Overview Panel
• • • • Reviewed budget cuts that had an Olmstead impact Assessment of political climate from a key legislative staff ally Overview of long-term care provisions of health care reform Academic research that would support removing the institutional bias of Medicaid
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Legal Strategies Panel
• • • Disability Rights California Reviewed Olmstead Litigation in California National Senior Citizens Law Center Reviewed National Medicaid Litigation The Bazelon Center for Mental Health Law Reviewed Critical National Olmstead Litigation
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Panel on Long-term Care System Reform
• • • Review of Advocacy from 1999 to Now Using Cost-Effectiveness Arguments in Advocacy Recommendations from the Author of:
Long-term Care Reform in California: Recommendations of the Home and Community-Based Long-term Care Report
http://www.hcbs.org/moreInfo.php/source/152/doc/2730/Ho me_and_Community-Based_Long-Term_Care:_Recommend • Strategies for Moving a Reform Agenda
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Successful Models Panel
• • • • The Developmental Disability System (Our Lanterman Act) Mental Health Community-Based Models An Effective County-Based System – San Francisco Expanding Successful Transition Services in California (California Community Transitions – our Money Follows the Person program)
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What We Learned from DEMOS Communications Training
• • • • Research-based Communications Strategies for Conveying the Positive Role of Government in Addressing the Common Good Dominant Stories Shape Understanding (Hidden Reasoning) Critical Role of Master Narratives Ways We Communicate that Make Things Worse (For Example, Triggering Independence Rather than Interdependence, Conveying Stories of Desperation Rather than Aspiration)
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What We Achieved
• • • • • Successful Collaboration with DRC in Planning Event Developed Outstanding Content Increased Relationships and Cross-Pollination of Work Excellent Participation and Excitement Set Stage for Participation in Larger Foundation Sponsored Collaborative Working on Long-term Care Systems Reform (SCAN Foundation Initiative)
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What We Didn’t
• • • Differences in Approaches Emerged Participatory Workgroups Proved Difficult to Sustain Most Strategies Will Take a Longer-term Effort than the Project Will Last
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Olmstead Summit Resources
• All PowerPoint Presentations and Handouts from the Summit, including the DEMOS Communications Training, May Be Found at Our Website: www.californiansforolmstead.org
Olmstead Summit under California
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III. Key Policy Work
Hopes and prayers, the general desire to do good without knowing how, seem to us frail reeds on which to lean, though these are the bases on which many programs are begun.
-Pressman and Wildavsky, Implementation, 1984
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Approaches
• • •
Articulate a Theoretical Framework Utilize Policy Analysis Promote Long-term Care Reform Strategies Derived from Best Practices
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Policies Imply Theories: Articulate a Theoretical Framework
• • • Social Justice and Consumer-Driven Orientation The Ecological Systems Model is an Overall Framework (Also described as Person-in environment, Whole Person, or Bio-Psycho Social-Spiritual Approach) Within this, the Strengths Perspective, Wellness Perspective, Family Theory, Culture Theory, Empowerment Theory, Recovery Model and Resilience Model are Useful
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Steps in Policy Analysis
-
Eugene Bardach
1) Define the Problem 2) Assemble Some Evidence 3) Describe Potential Options or Interventions (Including the DO NOTHING Alternative) 4) Select Criteria that Will Define Success (Including Cost-effectiveness)
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Steps in Policy Analysis -Eugene Bardach, cont’d.
5) Project the Outcomes of Each Alternative (Including Consideration of Unintended Consequences) 6) Confront the Trade-offs (Sometimes Called a Cost-Benefit Analysis) 7) Decide Between Options 8) Communicate Your Analysis in Simple Terms
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Describing Potential Options: Focus on Best Practices
• • • Characteristics of Effective State Long-Term Care Systems (Washington, Oregon, Vermont) Considering Best Practices in a State More Like California – Pennsylvania’s Successful Transition Services Characteristics of Effective County Long-Term Care Systems (San Francisco)
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Effective State Long-term Care Systems
• Washington State began by defining a strong statement of Vision and Values that guided the development of the long-term care system.
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Washington State Vision
• • • Consumer choice should drive the long-term care system.
Quality of life is as important as quality of care.
No one service is more important than another – the most important service is the one the consumer wants and needs.
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Values
• • Persons with disabilities and their families are entitled to maximum feasible choice and participation in selecting care settings and providers.
Persons with disabilities have the right to expect “quality of life,” personal dignity, maximum feasible independence, health and security.
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Values, cont’d.
• • People with disabilities have a right to choose and direct a care plan involving “managed risk,” in exchange for the advantages of personal freedom.
The array of public service options and individual consumer choices may be bounded by reasonable considerations of cost effectiveness.
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Nine Critical Elements of the Washington State Long-Term Care System
1.
2.
3.
4.
A strong statement of mission and values to guide system development A single organizational unit in state government to plan, develop and operate the long-term care system Single budget with flexibility and authority to spend on a varied array of long-term care services Process for assuring quality oversight throughout the system
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Nine Critical Elements of the Washington State Long-Term Care System, cont’d.
5.
6.
7.
8.
9.
Strong and organized stakeholders and advocates A process for resource development that meets consumer demand Fast, timely and standardized financial and functional eligibility that generates reliable data Care coordination system with capacity to provide assistance and oversight for consumers Fair rate setting and contracting process for providers
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Recognizing Pillars To Build Upon
•
A Comparison of Core Elements in 3 States with Effective Long-term Care Systems:
– Washington – Oregon – Vermont
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Core Element
Vision, Values Consistent w/Consumer Choice Single Org. Unit in State Government Single Budget w/Flexibility to Spend on Array of Serv.
Comparison of Core Elements
Washington
YES YES YES Quality Assurance Process Strong, Organized Stakeholders & Advocates YES YES Sustainable Resources to Meet Consumer Demand (Efficiencies + Tax Rev) Fast, Timely & Std Financial, Functional Eligibility Care Coordination System w/Effective Transitions Fair Rate Setting and Contracting Process YES, although proving weak in recession YES YES YES
Oregon
YES YES YES YES YES YES
Vermont
YES YES YES YES YES NO – ONLY EFFICIENCIES --Reason for Current Erosion of System NO - ONLY EFFICIENCIES – Utilized Homecare Tax – Erosion YES YES NO – Small state, do not have much problem w/this YES YES
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Effective Practices from States that are More Like California
• Pennsylvania is a leading state in transitioning people from nursing homes. – It is more like California in that it has a strong county-based system.
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Targeted initiatives
Pennsylvania’s MFP Transition Program
• • • In 3 ½ years, PA transitioned 1,600 persons from nursing homes. Scaled to CA, that would be 4,600 persons per year.
They estimate their savings to exceed over $200 million in nursing home expenditures.
Roughly 1/3 of all transitions do not require state funded services following transition.
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How?
• Funding: They started with a Money Follows the Person Grant, and added General Fund dollars. In 2008 they invested $10 million, in 2009 $14 million. – They use the general fund dollars to provide the most flexible program aspects. They also have a line item in each state waiver to support transition.
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How? cont’d.
• Reimbursement Structure: They have 80 transition providers and pay them both for time spent w/consumers as well as for benchmarks (30,90,180, 270 and 365 days living in the community).
• Housing: Intense collaboration at Cabinet level between LTC and state Housing Finance Agency. Regional housing staff co-located in transition agencies. Preferences for people transitioning, rental assistance, and renter’s training programs.
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• • •
Characteristics of Effective County Long-Term Care Systems
Utilized in San Francisco, Informing in Sonoma and San Diego • Consumer-driven Single Point of Entry (allows quality assurance) Comprehensive Package of Services that are Tailored to the Individual and
Can Change with His or Her Needs
Seamless Transitions Between Care Settings
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• • • •
Characteristics of Effective County Long-Term Care Systems, cont’d.
• Package Designed on Assessment, with Consumer Choice Funding for Services Array of Services Clear Lines of Responsibility and Oversight Flexibility to Make Changes
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System Change: The Washington State Long-Term Care Forecasting Commission
• • • As a result of their effective long-term care system, policymakers have confidence that spending these funds does actually save the state money.
Solid assessment data allows the Commission to project total need for home and community-based services.
The Governor and the Legislature agree without further ado to put the funding recommended by the Forecasting Commission into the budget for HCBS.
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System Change: The Washington State Long-Term Care Forecasting Commission, cont’d.
• Successful policies should take advantage of the effectiveness of statewide coordination as well as the efficiencies of the local delivery system, and have clearly defined state and county roles.
• There must be careful planning for these roles to be delineated, integrated and implemented. does not happen and it is critical to successful outcomes.
This usually • Never underestimate the power struggle between state and county government.
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System Change Opportunities In Federal Healthcare Reform
• • • In addition to expansion of health insurance coverage, created a long-term care framework CLASS Act – Long-term care insurance, no exclusion for pre-existing conditions, 5 year vesting period, $50 per day cash benefit to purchase services and supports Community First Choice – increases Federal share of community-based attendant services
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System Change Opportunities In Federal Healthcare Reform, cont’d.
• • • • • • Home and Community-Based Services State Plan Option Expands and extends Money Follows the Person demonstration projects Extends spousal impoverishment protections Funding of Aging and Disability Resource Centers Care Transitions Program Support for the Direct Care Workforce
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Draft California LTSS System Principles As Proposed, Not Yet Adopted Mission Statement
• The California Collaborative advocates for the dignity, care, maximum independence, and the physical, mental and economic well-being of Californians who experience disabilities, functional impairments, and chronic conditions. The Collaborative supports policies that prevent people from becoming impoverished, as well as a system of high-quality, cost-effective long term services and supports that strengthen the person, his or her family, and caregivers.
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Draft California LTSS System Principles As Proposed, Not Yet Adopted, cont’d.
Definition: Long-Term Services and Supports
• Long-term services and supports refer to a wide range of personal, medical and social/financial assistance needed by persons with functional limitations over an extended time. The services may be publicly or privately financed, delivered in a wide range of settings, and may change as the needs of the individual who uses the services change.
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Statement of Principles
The Collaborative Endorses a System of Long-Term Services and Supports Based on the Following Ten Principles:
1.
2.
3.
4.
5.
Dignity: The services are grounded in respect for the person who uses them.
Choice: The services are driven by the preferences of the people who use them and access to all types of services is provided on an equal footing.
Flexibility: The services are comprehensive and flexible enough to meet changing needs and incorporate new modes of service and supports.
Quality: The services system values and rewards high-quality care.
Legality: The services are consistent with the legal rights of individuals who use them.
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Statement of Principles, cont’d.
6.
7.
8.
9.
Cultural Competence: The services are appropriate and responsive to the needs of underserved populations.
Accessibility: The services are easy to locate and use and are physically and programmatically accessible.
Affordability: The services are cost-effective for the person and the system.
Inclusive: The services recognize and support high quality paid and unpaid caregivers.
10.
Independence: The services support maximum independence and quality of life.
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Conclusion Community-Based Organizations have to become the key engine for policy development. We must increase our policymaking capacity to meet this challenge.
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Thank You
Laurel Mildred, MSW Olmstead Advocacy Director California Foundation for Independent Living Centers 1234 H Street, Suite 100 Sacramento, CA 95814 (916) 325-1690 voice (916) 325-1695 TDD [email protected]
www.californiansforolmstead.org
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CIL-NET Attribution
Support for development of this training was provided by the U.S. Department of Education, Rehabilitation Services Administration under grant number H132B070002-10. No official endorsement of the Department of Education should be inferred. Permission is granted for duplication of any portion of this PowerPoint presentation, providing that the following credit is given to the project: Developed as part
of the CIL-NET, a project of the IL NET, an ILRU/NCIL/APRIL National Training and Technical Assistance Program.
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