DOORS: Individual Budgets DOORS: Individual Budgets Based on Individual NeedsBased on Individual Needs

Jon Fortune, EdDJon Fortune, EdD

Wyoming Department of HealthWyoming Department of HealthDevelopmental Disabilities DivisionDevelopmental Disabilities Division

IASSID World Conference

Montpellier, France

June 15, 2004

The

ETERNAL QUESTION:

How do we deliver what we have

to the people who need it most ?

Before

Unexplained48%ICAP

37%

Services9%

Geographic1%

Provider5%

After (2003 Adults)

Client Char.48%

Services20%

Unexplained25%

Day2%

Residential5%

Introduction

DOORS Model Stepwise regression Individual budget for each person

served for use by the local team Uses regular Medicaid HCBS DD waiver Funding related to characteristics of

person Wyoming financial architecture

Overview - History & Results Began in July 1998 for adults and in

January 1999 for children No hearings to date Some requests for State Level of Care

Review Focus on the needs of the person

served Very stable for financial planning

Agenda What did we tell the families and people

served? Campbell & Heal, 1995 AJMR Rhoades & Altman, 2001 MR ICAP items and other data pieces DOORS - Gary Smith & Bob Clabby Model can be done on a spreadsheet

N e w W y o m i n g P e o p l e S e r v e d & W a i t i n g f o r W a i v e r S e r v i c e s

0200400600800

100012001400160018002000

W aitin gS erved

Model - “A tentative description of a system or theory that accounts for all of its known properties.” (American

Heritage Dictionary, 1985) - we are referring to a mathematical formula which attempts to describe the relationship between independent predictors and dependent measures of interest like the budget for reimbursement

Assumptions:

1. Individual People have needs, not providers, agencies, or groups.

2. Individuals with greater needs should have access to more resources; those with lesser needs should get less.

3. No two people have the same needs, supports and priorities. The word “Individual” must mean something.

Assumptions: (cont.)

4. Individuals and their teams know best what services are most important for that person, not the State.

5. People should choose providers, not the other way around.

6. It is possible to make it happen.

Overview - StrategyFairness, equitability, explicabilityMatch resources and individual needsAbility to handle special

cases In a time of limited resources - focus

on those with greatest demonstrated need

Overview - Strategy Find predictors that we can

use for constructing a statistical model, or formula, to generate predicted budget for each eligible person on the waiver

What factors explain variance? (Remember, your results at home should vary!)

Autism, Deafness, Mental Illness, level of MR, health limitations, psychotropic meds, lives with family, ICAP Broad Independence, ICAP Gen Maladaptive, lives independently, SE, etc.

RobustnessThe techniques are often powerful enough to be able to overcome minor error and work well

All the predictors work together as a team, like the attacking army on a chessboard

Column A Column B Column C Column D Column E

Parameter Variable Estimated

Predictor Variable Estimate Value B x C Range

Base Amount (Intercept) 4.39005 1 4.39005

ICAP Measures

ICAP Broad Independence -0.00279495 404 -1.1291598 $7,487

ICAP General Maladaptive -0.004806757 -12 0.057681084 $1,887

Age -0.002205103 32 -0.070563296 $1,124

Dx: Autism? 0.088635 0 0 $881

Dx: Brain/Neurological Damage? 0.045409 0 0 $425

Dx: Chemical Dependency? 0.11922 0 0 $1,230

Dx: Deafness? 0.12074 0 0 $1,248

Level of Mental Retardation 0.030344 3 0.091032 $1,131

Psychotropic Medications? 0.071711 0 0 $653

Lives with Family? -0.14618 0 0 $1,200

Lives Independently? -0.25273 0 0 $1,757

Independent with Monitoring? -0.078247 0 0 $663

Sheltered Workshop? -0.056035 0 0 $489

Supported Employment? -0.092672 0 0 $779

Competitive Employment? -0.14002 0 0 $1,107

Home & Community-Based Services

Residential Services? 0.24897 1 0.24897 $1,926

Day Habilitation? 0.10444 1 0.10444 $878

Nursing? 0.10268 0 0 $943

Personal Care? 0.1309 0 0 $1,420

Psychological Services? 0.083741 1 0.083741 $800

Second Assessment? 0.03118 0 0 $284

In-home Services? 0.066377 0 0 $637

Sum: Predicted Log10 Monthly Rate 3.776190988

Predicted Monthly Rate (10 to the power) $5,972.98

Database Invaluable

Information about people served and service use is needed

Regression - Comments, Conditions & Caveats: It is best to have “orthogonal” regressors;

ones not correlated with each other, not collinear

An important regressor might have a large probability value (i.e. may not be statistically significant) if the sample is small, if the regressor measures a narrow range with large measurement errors, or a closely related regressor is included

LimitationsThere are someHold some dollars for

exceptional casesThere is a budgetThis surprises no one

Does not ensure enough money Can provide a fair way to distribute the

money available Does offer a way for money to follow

the person served Provides the local team an

understandable budget that they can use in pursuit of choices & preferences

Wyoming Financial Architecture

1. DOORS to match dollars to people

2. Clear assignment of authority to make decisions about services to local team that supports each person

3. Authority for individuals to select their own service coordinators

Wyoming Financial Architecture

4. Resolute adherence to principle that individuals and families have free choice of service providers

5. Policies that encourage – rather than impede – new providers stepping forward to offer supports to individuals

The Four “P”s

1. PERSONAL* Individual, not group* Real information about each person* Model comes from individual characteristics,

not the other way

The Four “P”s

2. PORTABLE * Person has funding, not

provider * Person chooses provider * Funding moves with the

person * No “guaranteed clients”

The Four “P”s

3. PRIORITIZED

* Person & Team set priorities

* People with greatest need get most

The Four “P”s

4. PREDICTABLE

Both the Individual and System know & plan within their limits

Special Thanks toProfessor Laird Heal

Bradley K. Hill (ICAP)

Wayne Johnson

Edward M. Campbell, Ph.D.

Don Severance

“DOORS” Contact Information

Jon Fortune, Ed.D.

Jfortu@state.wy.us

DDD Wyoming Web Site

http://ddd.state.wy.us