preconiii - The NADDthenadd.org/wp-content/uploads/2012/10/preconiii.pdf · Sherry Peters, MSW, ACSW, Psychiatric Residential Treatment Facility (PRTF) Waiver Initiative, Georgetown

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Key Policy Issues Affecting Health Care Access for Individuals with a

Developmental Disability and Co-Occurring Behavioral Health Disorders:

Understanding the Implications of Three National Policies on Home and

Community- Based Care .

NADD 29TH ANNUAL CONFERENCEMental Wellness in Persons with IDD and ASD: Innovation,

Collaboration & Quality of Life

PRE CONFERENCE SYMPOSIUM III

OCTOBER 17, 2012

SYMPOSIUM ADDRESSES

THREE POLICY ISSUES

1. Overview of Presentation by Understanding the Supreme

Court Olmstead Decision Ensuring Community Integration and

Resulting State-Based Federal Consent Decrees

Eileen Elias, Moderator, M.Ed., Director Disability Services,

JBS International, Inc. , North Bethesda, MD

2. Individuals Who are Dually Eligible for Medicaid and Medicare

Joan Beasley, PhD, START Services, University of New

Hampshire, Institute on Disability, Concord, NH

3. Health Homes/Patient Centered Medical Homes

Sherry Peters, MSW, ACSW, Psychiatric Residential

Treatment Facility (PRTF) Waiver Initiative, Georgetown

University’s National Technical Assistance Center for

Children’s Mental Health, Washington, DC

Key Connecting Factor

Across the Three Policy IssuesSolutions for tomorrow’s world

• Understanding the Olmstead Decision

• Recent Olmstead decisions

• Role with the Health Care Reform

• Questions and Answers

Presentation Topic Areas

• Thirteen years ago, the U.S. Supreme Court ruled in Olmstead v. L.C. that Title II of the ADA prohibits the unnecessary institutionalization of people with disabilities (DOJ Website).

• In the words of the Court, services to people with disabilities must be provided “in the most integrated setting possible.”

• As states struggle with budget shortfalls, lawmakers have considered or made cuts to services that place at risk the ability of people with disabilities to remain in or transition to the most integrated setting.

• The Olmstead decision has become a major component of ADA enforcement by the Department of Justice (DOJ) and its Assistant Attorney-General for Civil Rights, Tom Perez through 40+ Olmstead matters in 25 states.

Overview of the Olmstead Decision

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Recent Olmstead Decisions

• On September 20, 2012, the Court granted the United States' June 2011 request to intervene in a pending lawsuit against the State of Texas alleging violations of Title II of the ADA and Section 504 of the Rehabilitation Act for unnecessarily segregating individuals with developmental disabilities in nursing facilities.

• The plaintiff class consists of approximately 4,500 adults with developmental disabilities currently confined to nursing facilities and thousands more at risk of nursing facility placement.

Recent Olmstead Decisions (continued)

• On April 12, 2012, DOJ filed a Statement of Interest in Lane v. Kitzhaber, asserting that “the (Oregon’s) integration regulation prohibits the unnecessary segregation of persons with disabilities (intellectual and developmental disabilities) by public entities in non-residential settings, including segregated sheltered workshops where they have little interaction with individuals without a disability.


• On January 26, 2012, DOJ concluded an Olmstead investigation in Virginia with an agreement that Virginia will create approximately 4,200 home- and community-based waivers over 10 years for people (individuals with developmental disabilities) who are on waiting lists for community services or transitioning from institutional settings.

• Virginia also agreed to create a comprehensive community crisis system with a full range of crisis services, including a hotline, mobile crisis teams, and crisis stabilization programs, to divert individuals from unnecessary institutionalization or other out-of-home placements.


• On January 9, 2012, DOJ filed a Statement of Interest regarding a plaintiffs’ challenge to a 20 percent reduction in personal care services provided through California’s In-Home Support Services (IHSS) program. IHSS is designed to enable seniors and people with disabilities to avoid hospitalization and institutionalization.


• In December 2011, DOJ issued a Findings Letter concluding that Mississippi is in violation of the ADA’s integration mandate to provide meaningful opportunities for people with disabilities to live in most integrated community settings.


• On July 12, 2011, DOJ filed an amicus brief supporting California adults with physical and mental disabilities, who argued that State policies place them at serious risk and are actionable under the ADA.

• On July 6, 2011, DOJ announced it had entered into a comprehensive agreement with Delaware to resolve violations of the ADA within the State’s mental health system.

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Health Care Reform: Continuing State Actions

2009 Bazelon “Still Waiting: The Unfulfilled Promise of Olmstead” Report recommendations:

• States must identify how many people with disabilities are unnecessarily segregated for care and how to reintegrate them, shifting funds from institutions to community-based services.

• Savings can occur by linking Olmstead programs implementation to health care reform in order to provide community services to people with disabilities.

• States waste funds by placing people into institutional settings that are more expensive and often less effective than community-based settings.

• Support judicial nominees who understand and will uphold Olmstead, the ADA, and other civil rights laws.

Olmstead Implications

‘Dual Eligibles’• Right to have a full community life supported

by coordination of care.

Health & Medical Homes• Integration of care• System of care

Thank You

Questions?

Contact Information

Eileen Elias, Senior Policy Advisor

Director, Disability Service Center

JBS International

5515 Security Lane, Suite 800

North Bethesda, Maryland 20852

Work Phone: 240 645 4534

Cell: 240 380 0431

Email: [email protected]

Dual Eligible Medicare/Medicaid

with Dual Diagnosis MI/DD

Improving care to individuals enrolled in both Medicare and Medicaid Programs in the U.S.

Joan B. Beasley, Ph.D.

UNH Institute on Disability

What does each pay for?

• Medicare is a federal health care program that provides coverage to the elderly and certain people with disabilities. It covers acute care, such as hospital stays and emergency room visits, outpatient health care and prescription drugs. No income requirement and services are the same all over the country

• Medicaid is a federal and state partnership program that provides coverage to low income people with limited resources, to a number of groups including those with disabilities. Medicaid pays for long term community based and institutional care, services vary by the state.

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Dual eligibility

• 9 million people are dual eligible mostly fragile elderly in poverty

• 3 million are under age 65

• More than half of this group have cognitive or mental impairments (4.5 million)

• Frequently have multiple or chronic health conditions(Alzheimer's, asthma, diabetes, heart conditions, epilepsy, etc.)

• Estimated that 18% of all people with ID are dual eligible ( this does not include non ID autism numbers)

• Tend to have lower incomes

Impact on services and cost

• Lack of coordinated care, lack of

communication and collaboration across

systems

• Providers have incentives to shift costs

from one program to the other, which can

lead to greater fragmentation of care

(hospitalization vs. waiver services, i.e.)

and ineffective care

Why does this matter?

• In 2008, dual eligible pop constituted 20 % of Medicare population spent 31% of funds

• Represented 15% of Medicaid population but spent 39% of all funds

• Lack of coordination inflated costs in both programs, but especially the Medicaid program (i.e., ER visit, no help, stuck picked up by Medicaid program)

The health care challenged for Dual

diagnosis population• Estimated that 18% of ID pop is dual eligible

• 1% of the population have ID (3 million people): estimated that 20% have dual diagnosis (600,000 people)

• Estimated that 20% has dual diagnosis: most complex needs often dual eligible

• Estimated that dual diagnosis may represent as many as 10% of all dual eligible under the age of 65 in the U.S. (300,000 people)

• Many are children, transitional youth (START data)

• Some in facilities

• Considered high cost to Medicaid and Medicare programs

• Have an average of 4 chronic health conditions (START data)

• Have an average of 4 psychotropic medications (START data)

• Frequent users of emergency services

• Multiple medication users poor outcomes

• Poor access to preventative health care and mental health care

Challenges to effectiveness

The 3 A’s

• Access

• Appropriateness

• Accountability

Proposed solutions

• Medical homes that utilize both Medicaid

and Medicare, integrated care

• Systems linkages: innovations to foster

improved cross systems collaboration (i.e.

START)

• Managed care, with blended funding

streams, control costs, record keeping, etc.

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Sources

• Health Policy Brief, Kaiser Foundation

• NCSTART Annual report

• NHSTART Annual report

• RHC/START Children’s program

Medical Homes/Health Homes

October 17, 2012

Sherry Peters, MSW, ACSWPRTF Waiver Initiative Director

© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY© 2010 NATIONAL TECHNICAL ASSISTANCE CENTER FOR CHILDREN’S MENTAL HEALTH, GEORGETOWN UNIVERSITY

Medical Homes and Health Homes (Section 2703)

Opportunity for integration and coordination of care to treat the whole person:

Medical

BehavioralLong-Term Care


Expected Outcomes

Lower rates of emergency room use

Reduction in hospital admissions and re-admissions

Reduction in health care costs

Less reliance on long-term care facilities

Improved experience of care

Improved quality of care outcomes


How are they related?

Medical Home

Health Home (Section

2703)


Medical Homes

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Health Homes (Section 2703)


Health Home Enhanced Federal Match (90% for 8 quarters) on Required Services:

Comprehensive Care

Management

Care Coordination

Health Promotion

Transitional Care

Individual & Family Support

Referral to Community & Social Supports


States with Approved Health Home State Plan Amendments

Iowa Missouri (2)

New York

North Carolina Oregon Rhode

Island (2)


Additional Information

11/16/10 Health Homes State Medicaid Director Letter: http://downloads.cms.gov/cmsgov/archived-

downloads/SMDL/downloads/SMD10024.pdf

Technical Assistance Contractor: Integrated Care Resource Center:

http://www.integratedcareresourcecenter.com/

Patient Centered Medical Home Resource Center: http://www.pcmh.ahrq.gov/portal/server.pt/communit

y/pcmh__home/1483


Contact Information

Sherry Peters

[email protected]

202-687-7157

Documents

preconiii - The NADDthenadd.org/wp-content/uploads/2012/10/preconiii.pdf · Sherry Peters, MSW, ACSW, Psychiatric Residential Treatment Facility (PRTF) Waiver Initiative, Georgetown