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Beyond Olmstead: Community-Based Services for All People with Disabilities
Mary Jean Duckett, M.S.P., Director, Division of Benefits, Coverage and Payment, Disabled and Elderly Health Programs Group, Center for Medicaid and State Operations, Centers for Medicare & Medicaid Services (CMS), U.S. Department of Health
and Human Services, Baltimore, MD.
Long-term care policy and planning at both State and Federal levels are being driven by three factors:
- Changing demographics: The elderly population is expected to double in the next 30 years.
- Consumer involvement: Consumers are becoming increasingly involved in their own care and the care of their loved ones, are making new demands on the system, and have higher expectations as to receiving care in the community.
- Legal challenges: In the wake of the Americans with Disabilities Act, the Olmstead decision, and State court actions, consumers are exercising their legal rights to "access to services" with "reasonable promptness" in the "most integrated" setting.
Several factors impede the ability of State and Federal policymakers to respond effectively to these challenges:
- Lack of infrastructure at State and Federal levels, as evidenced by limited planning and management capability, including lack of adequate information systems.
- Quality assurance and quality improvement system weaknesses.
- Inadequate availability of services, providers, or both; lack of effective models to recruit, train, and support workers, especially those dispersed throughout the community.
- Lack of clarity about what is being offered to the public (e.g., "fuzzy" product).
- Weaknesses in the social contract that undermines public trust in long-term care systems. Effective systems must communicate positive results to the public and legislatures if they are to enjoy sustained public support.
- Challenges in building community that threaten the fundamental principle underlying the development of long-term care alternatives.
States and the Federal Government need to model effective communities in their relationship by communicating in an atmosphere characterized by respect, open dialogue, collaboration, and absence of cynicism.
The Centers for Medicare & Medicaid Services (CMS) is responding to States' needs by:
- Making funding available.
- Providing technical assistance.
- Employing research contracts.
- Developing a legislative and regulatory agenda.
CMS is making funding available to States in six areas:
- Nursing Facility Transition Grants ($10-14 million): To help people make the transition from nursing facilities to the community.
- Community Integrated Personal Assistant Services and Support Grants ($5-8 million): To support State efforts to improve consumer-directed personal assistant services.
- Real Choice Systems Change Grants ($41-43 million): To help States design and implement improvements in community long-term care support systems.
- National Technical Assistance Exchange for Community Living Grants ($4-5 million): To provide technical assistance training and information to States, consumers, families, and other agencies and organizations.
- Ticket to Work, Work Incentives Improvement Act Infrastructure Grants ($150 million): To support State efforts to encourage employment among persons with disabilities.
- Ticket to Work, Work Incentives Improvement Act Demonstration Grants ($250 million over 6 years): To enable States to provide Medicaid to persons at risk for becoming blind or disabled in order to measure the effects of early intervention on the ability of participants to retain competitive employment.
- Providing Technical Assistance: CMS is working with the Office of the Assistant Secretary for Planning and Evaluation to create a resource network for States on the Web. The resource network will sponsor small group meetings among States focusing on topics such as long-term care systems change, self-advocacy, building infrastructure, and consumer-directed services.
- Supporting Research: CMS has contracted with researchers to compile data sets and informational materials useful for long-term care planning for community services at State and Federal levels; improve and automate the HCFA 372 annual cost report for home and community-based waiver programs; and compile "promising State practices" in delivering community services.
- Developing a Legislative and Regulatory Agenda: CMS is conducting a comprehensive review of existing laws, regulations, and policies in response to President Bush's June 19th Executive Order directing Federal agencies to ensure the timely implementation of Olmstead. CMS has identified one legislative barrier to home and community-based services for children and is seeking a legislative amendment from Congress.
Finally, CMS has three initiatives under way to address quality improvement in the provision of waiver services:
- First, the redesign of the Federal waiver monitoring tool.
- Second, working with MedState, the development of quality measures.
- Third, the establishment of a national contractor for quality assurance and quality improvement.
Attachment: States and territories that have been awarded or are pending receipt of awards for system change "starter grants" as of 6/20/01. Baltimore (MD): U.S. Department of Health and Human Services, CMS, Center for Medicaid & State Operations;2001 Feb.
Fact sheet: Real choice systems change "starter grant". Baltimore (MD): U.S. Department of Health and Human Services, CMS, Center for Medicaid & State Operations;2001 Mar.
Fact sheet: Systems change grants for community living. Baltimore (MD): U.S. Department of Health and Human Services, CMS, Center for Medicaid & State Operations;2001 Mar.
Medicaid eligibility groups and less restrictive methods of determining countable income and resources: Question and answer. Baltimore (MD): U.S. Department of Health and Human Services, CMS, Center for Medicaid & State Operations;2001 Jan.
Medicaid eligibility groups and less restrictive methods of determining countable income and resources: Mandatory eligibility groups. Baltimore (MD): U.S. Department of Health and Human Services, CMS, Center for Medicaid & State Operations;2001 Jan.
Medicaid eligibility groups and less restrictive methods of determining countable income and resources: Optional eligibility groups. Baltimore (MD): U.S. Department of Health and Human Services, CMS, Center for Medicaid & State Operations;2001 Jan.
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