The Demonstration to Maintain Independence and Employment

The Demonstration to Maintain Independence and Employment

Assisting Individuals with Disabilities Remain Employed

What is DMIE? DMIE provides medical and employment services to

workers with potentially disabling health conditions.

The DMIE uses a rigorous experimental model, in order to determine the effect of health and employment supports on -

◙ Health◙ Dependence on public benefits such as federal Social

Security disability programs

Why DMIE?

A person’s health affects their ability to work.

Many uninsured workers with disabilities lose employment and turn to federal assistance.

By 2003, disabled US workers accounted for nearly $65 billion of $77 billion in federal disability benefits.

Traditional Medicaid programs for people with disabilities do not provide “preventive care”.

DMIE offers a unique opportunity to keep workers healthy and working.

“Gold Standard” Evaluation Rigorous experimental/randomized control design to

ensure strong, policy relevant data Evaluation of quantitative and qualitative data, including:

◙ Changes in health status◙ Income◙ Employment◙ Quality of Life◙ Disability Status◙ Cost-offsets◙ Program Cost effectiveness

Each state must have an independent evaluator Mathematica Policy Research performs the national

evaluation of DMIE

Why Continue DMIE?

Preliminary findings suggest: ◙ Potential to reduce public expenditures for disability

benefits (less people applying)◙ Potential to reduce employer costs related to worker

health problems

Provides data to support development of longer term reforms

May provide a replicable infrastructure of services to prevent disability

Why Do We Need an Extension?

To move from a “one time experience” to conclusions, States need more time

Longer studies will produce –

◙ Better measure of key outcomes (health, income, disability status, cost offsets, cost effectiveness)

◙ Better data for policy development

Need to Act Now If there is a gap in funding, it will be difficult to restart

these on-going projects

CMS must have time to amend grant awards

Revised terms and conditions will be needed

Match must be secured ◙ Bi-annual State budgeting processes will need to anticipate

extension or termination

States will need to amend vendor contracts

For More Information

Nanette Relave, DirectorCenter for Workers with Disabilities, NASMD◙ [email protected]◙ 202-682-0100 x241

mailto:[email protected]

The Kansas Demonstration to Maintain Independence & Employment

Preliminary findings about participants’ health, service utilization and employment

Jean P. HallUniversity of Kansas

Target Population

Enrollees in the Kansas High Risk Pool health insurance program; DMIE provides Medicaid-like coverage as wraparound to the high risk plan, which has relatively limited coverage

Historically, people in the Kansas high risk pool have transitioned to federal disability benefits at a rate eight times that of the general population

The Kansas High Risk Pool

Coverage of last resort for Kansans who are medically uninsurable in the private market (one of 34 pools nationally)

As a non-group plan, coverage is more expensive and less comprehensive than employer-based insurance

A 25 year old non-smoking female would pay $624/month in premiums for a plan with a $1500 deductible and 30% coinsurance

Preliminary Findings About Study Participants

80% have at least some college Median annual income of $30,000 70% are self-employed Despite risk pool coverage, 27% report having

medical debt Many report delaying or forgoing care due to

lack of coverage or expense Experience a range of serious and potentially

disabling conditions including: diabetes, mental illnesses, cardiovascular disease, cancers and back and joint conditions

From participants About their coverage through the high risk pool:“We’re in a Catch-22: if you can’t get your health better because the insurance doesn’t cover services, then you can’t get a full-time job, so then you can’t get good insurance to help get your health better.”“I have car accident insurance, not wellness insurance.” About the DMIE:It [the DMIE] increases your quality of life. You stay healthier because you have the enhanced benefits to help you stay healthy.

Case Studies

Ms. A has Crohn’s disease and arthritis in her feet and ankles. The DMIE has allowed her to get the adaptive shoes and leg braces she needs to be able to work. She reports that, without the DMIE, she would have applied for SSDI and been fully disabled by now.

Mr. B says the DMIE has improved his life: “Being able to have that surgery for a detached retina and being able to see again was fantastic. I am a music teacher so it would have affected me greatly had I not had it repaired.”

Need for an extension Although a small minority of Americans

acquire a disability immediately prior to applying for Social Security disability, the large majority experience a gradual worsening of medical conditions over time; health insurance coverage is a major factor in the decision to apply for disability benefits (Miller 2005).

Hadley (2003) found that improving health status from “poor to fair” to “good to excellent” would increase work efforts and earnings by 15 to 20%.

Without an extension

Programs will not have sufficient time to demonstrate: Prevention of transition to federal

disability programs Increases in work efforts and health

status An important part of the Ticket

legislation, i.e., disability prevention, may not be realized and federal disability rolls will continue to grow

Kansas DMIE contacts

Mary Ellen WrightProgram DirectorKansas Health Policy [email protected](785) 296-5217

Jean HallExternal EvaluatorUniversity of [email protected](785) 864-7083



Minnesota’s Demonstration to Maintain Independence and Employment

Stay Well, Stay Working

Minnesota’s Demonstration to Maintain Independence and

Employment


The Commitment to a DMIE1999 – Congressional Authorization2003 – MN Legislature Authorized DMIE2004 – MN Submits Proposal to CMS2005 – Planning Grant Received2006 – Protocols Approved (July)2007 – Enrollment Began (January)2008 – Enrollment Ends (8-31)2009 – Six-Month Notification to Enrollees

(3-31)2009 – Demonstration Authority Ends (9-30)


Desired Outcomes : Accessible, Responsive, Outcome Driven System

• Community Mental Health Reform• Managed Care Pilots Integrating

Health Care with Home and Community Based Services

• Health Care Reform


Who is Enrolled? (Current N=1000+)

Most common mental health diagnoses: Depression Anxiety Disorder Bipolar Disorder

95% desire to keep workingAverage monthly income: $1,577.31

13% college graduate - 43% high school/GED 9% married; 27% divorced; 59% never married

SF12* = 47 physical health, 36 mental health

* SF-12 is a measurement of overall health, including mental health. Scale of 0-100 (poor to excellent, 50 avg. for general population)


22


Value of the DMIE

• Building Stronger Community Capacity

• Intervention Before “deep-end” Services

• Evidence Based Practice and Person Centered


DMIE Is Working• Kim was able to get back on her anxiety medications

and reports more stability with her employer. • Kristin was drinking at work. She went through in-

patient treatment and was able to keep her job. • Jeff has difficulty interacting with people due to

schizophrenia. He was able to get a job as a delivery driver and is employed 30 hours per week.

• Mary’s Fibromyalgia and late night shift were causing fatigue. An employment counselor helped her get a day shift close to home so she can continue working.

• Todd knew he needed treatment that he wasn’t able to access and reported feeling suicidal. Through DMIE he received the treatment he needed.

• At least 9 people have reported choosing DMIE instead of applying for a disability determination.


Moving Forward

“This is good common-sense policy: providing preventive health coverage to working individuals with serious medical conditions before such conditions worsen to disabling level.”

Senator Patrick Moynihan,

Congressional Record 11-99


What to Leave Here With…“For the first time in over a year, I feel hope. With the services and support DMIE offers, I can begin to manage my chronic conditions better, find a permanent job, catch up financially and improve my life.”

Barb - DMIE participant 3/20/08


Minnesota DMIE Contact

• MaryAlice Mowry, DirectorStay Well, Stay Working– [email protected] – (651) 431-2384


Texas DMIE

Texas Department of State Health Services

04.02.08

Current Reality

• 28 percent of working adult Texans are uninsured

• Uninsured Texans with disabilities turn to federal programs for help when they become unemployed.

• This increases federal costs and erodes the local tax base which supports health care.

• 250,000 working age Texans with disabilities receive SSI (average of $412/ mo per person in 2005)

• 380,000 Texas workers with disabilities receive SSDI (average of $924/mo in 2005)

• 345,500 working age Texans with disabilities were on Medicaid in 2007. Expenditures were $3.5 billion. (In Harris County 48,600 cost $375.5 million)

04.02.08

Texas DMIE

• A model which can work in states where county governments address the health needs of low income workers

• Largest study population among DMIE projects (over 1600 participants)

• Randomized controlled trial• Intervention group receives enhanced

medical and vocational services

04.02.08

Current Texas Site: Houston

04.02.08

State / Local Partnership

UT Austin

Conduct independent evaluation

DMIE data system

Recruitment

Harris County

Hospital District Develop/

operate DMIE Health System

Provide match for Medicaid-like services

StateOversight

Federal LiaisonManage Project

04.02.08

Who’s in Texas DMIE?

• Adults (21 – 60) with disabling conditions

— Severe mental illness (schizophrenia, bi-polar disorder, major depression) – 12%, or

— Major physical conditions (e.g., diabetes, heart disease, MS, etc.) PLUS a behavioral health illness (depression, etc.) – 88%

• Low income – 90% are below 200% poverty, 60% are below 100% poverty

• Limitations in performing daily living tasks (40%)• A strong desire to continue working (80-90%)• Part or full-time jobs (20% are health care workers)• At significant risk of dependence (over 400 candidates applied

for disability before they could be recruited into the study)

04.02.08

Supporting Wellness

• Health services (physician, hospital, etc. )

• Enhanced health services

— Prescription medicine

— Enhanced psychological and neuropsychological assessments

— Improved access to outpatient mental health services (expedited office or outpatient visits)

— Chemical dependency treatment services

— Expanded Durable Medical Equipment

— Preventative and restorative dental treatment

04.02.08

Supporting Independence

• Individual planning addressing life and health issues

• Advocacy, direct services, motivational interviewing, coordination and intervention

• Assistance in connecting to other community resources

• Employment/Vocational supports including:— Vocational Assessment/Evaluation

— Collaboration with an Employer

— Vocational Support Groups

— Collaboration with Family/Friends

— Vocational Treatment Planning/Career Development

— Vocational Counseling

04.02.08

Texas DMIE Enrollment

04.02.08

How It’s Working

• Linking workers to vital health care services

• Providing help to gain, keep, improve employment

• Building upon local systems of care by better coordinating existing resources

• Hundreds are now getting help. Success stories include: — Mental health care and employer education result in secure and

stable job for formerly suicidal person

— Orthopedic shoes, health and job counseling allow a severe diabetic to keep working

— Health counseling, career planning result in full-time job for formerly unemployed person with multiple physical/mental disabilities

04.02.08

Future Texas Plans

Texas plans to extend / expand DMIE, should extension be included in the federal budget

— Continue Houston project through 2012

— Add second site - Bexar County (San Antonio) – important to determine if success can be replicated in Texas

For more information contact:

Dena Stoner, State Project Director

(512) 206-4851

[email protected]

Hawaii Demonstration to Maintain Independence and EmploymentUniversity of Hawaiì - Center on Disability Studies

April 15, 2008

Partnership for a Healthy WorkforceStrategy: Partner with employers to find ways to maintain a

healthy workforce

Committed Employers - $6.7 Million: Hawaii Business Health

CouncilTimes SupermarketRoberts HawaiiLongs Drug StoreRoberts HawaiiHawaiian Electric

Company, IncCentral Pacific Bank…and many more

Committed Agencies - $9.1 Million:

CMSHawaiì Dept of Human ServicesHawaiì Dept of Health

Oahu WorkLinksUniversity of Hawaiì – CDSHawaiì DLIRHI Division of Voc. RehabHawaii Disability Rights Center

Why do Employers Care?

Prevalence of diabetes in U.S.

• Approximately 17.5 million are diagnosed• National cost of diabetes exceeds $174 Billion

– $116 billion in excess medical expenditures– $58 billion in reduced national productivity

Prevalence of diabetes in Hawaii

• About 107,000 people living with diabetes• Estimated annual costs are more than $1 billion

– $764,400,000 for medical costs– $273,600,000 for indirect expenses – loss of productivity

Source: Diabetes Care, Volume 31, Number 3, March 2008 & National Diabetes Education Program www.ndep.nih.gov & National Diabetes Education Program, NIDDK, National Diabetes Fact Sheet HHS, NIH, 2005, www.ndep.nih.gov

A Possibility for Prevention

Goal: Develop, implement, and evaluate interventions that are intended to improve health care coverage and employment services for working adults with diabetes and potentially disabling conditions

Target Population: • Individuals diagnosed with diabetes or has

a Hemoglobin A1c 6.5+• Employed adults (40+ hrs. per month) • Resident of Oahu

Life Coaching – Benefits and Supports

Intervention: Off-site diabetes self-management support services.

Participants will meet with:• Pharmacist (Medication Therapy Management) • Life Coach (Use of a laptop and online coaching tool

to track goals)

Financial Compensation:• Medical, drugs, and supplies related to diabetes

Other optional services include:• Certified Diabetes Educator• Dietitian • Fitness Membership

Desired Outcomes for our Community

People working and living with diabetes will:• Improved health and productivity• Increase work hours• Reduce absenteeism • Reduce employee turnover• Improve job satisfaction and morale

Diabetes is Preventable and Treatable!

Listen to Our Participants

“I’ve lost over 25 pounds and feel better overall than I did prior to participating…my HbA1c has dropped from 7.0 to 6.2 percent

on my last blood test.” – Rodney

"It has given me positive feedback, encouraged me to set measurable short term goals to keep that positivity going

strong." – Anonymous

"Great program, kept me motivated and thinking about what I can do to help myself live a better/healthier life." – Brian

"With a life coach, you will have someone who can provide a different perspective, help set goals, and provide other

resources that may help you control this affliction.“ – Anonymous

Mahalo nui loa!

Contact information:

Rebecca Rude Ozaki, Ph.D.1-808-956-9376

[email protected]

University of Hawaii at Manoa – Center on Disability Studies1776 University Ave., UA 4-6

Honolulu, HI 96822


http://www.livehealthyworkwell.org/

Iowa DMIE: Former inmates with mental illness - Re-entry employment and support

Jennifer Vermeer

Assistant Medicaid Director

Iowa Medicaid Enterprise

Iowa Department of Human Services

Iowa DMIE – the benefit

DMIE Purpose – prevent disability and lifetime dependence on disability programs; support independence and employment.

Iowa is focusing on a unique population – individuals re-entering community from prison, with mental illness who are willing and able to be employed, but needing supports.

Studying the outcomes of this population will provide significant national benefit, because all states face these problems.

Iowa – Need DMIE grant extension to start

Unlike the other states, Iowa has just received grant approval.

Iowa needs the 5 year extension in order to start and implement our program.

No federal funds will be used for the prison services prior to release. Iowa is investing a significant 100% state funds contribution to the project for the re-entry services needed prior to release from prison.

The Problem: Lack of supports land mentally ill in prison

Nationally, as many as 1 in 5 prison/jail inmates are mentally ill. In Iowa, 1 in 3 inmates are mentally ill.

Former inmates have little to no access to mental health treatment outside prison, and are far less likely to be employed than other inmates (29% for mentally ill vs. 69% for other inmates) .

Without supports, more likely to eventually become permanently disabled and dependent upon public assistance programs.

National interest in ‘re-entry’ or rehabilitation programs for those coming out of prison. (‘Second Chance Act’ just signed). Mentally ill inmates pose particularly difficult challenges for re-entry and success in community.

Iowa’s DMIE Project

Target group - mentally ill inmates leaving prison with work history and ability to work.

Grant will provide appropriate community mental health and vocational supports to keep mentally ill former inmates employed, independent, and in the community.

Demonstrate higher employment rates, prevention of permanent disability.

Iowa DMIE: Multi-Agency partnership

Project is a partnership between 4 agencies: – DHS, Iowa Workforce Development, Department of

Corrections and University of Iowa.

DMIE has a very rigorous evaluation methodology – Experimental design & Control groups– Evaluation by University of Iowa

Over 5 years - $28.2 Million State funds, $56.7 million DMIE funds.

Iowa DMIE Program

Prior to release, intensive Life Skills training and Re-entry/transition planning with the inmate to prepare for community living (funded with 100% state funds).

DMIE - Community Supports:– Supported employment assistance – help planning for and

finding a job for when released. Includes supports for the employers.

– Medicaid coverage for mental health treatment and medications, includes intensive care management.

– Specialized community supervision. Employment is required for continued participation.

Iowa DMIE Contact

Jennifer Vermeer, Assistant Medicaid DirectorIowa Medicaid EnterpriseIowa Department of Human Services– [email protected]– (515) 725-1144


Questions?

Documents

The Demonstration to Maintain Independence and Employment