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Beyond Olmstead: Community-Based Services for All People with Disabilities

Planning & Budgeting


Susan L. Babin, M.P.A, Administrator, Department of Mental Health, Retardation and Hospitals, Division of Developmental Disabilities, Cranston, RI.

Jon Fortune, Ed.D., L.P.C., C.R.C., Adult Services Manager, Division of Developmental Disabilities, Wyoming Department of Health, Cheyenne, WY.

Rhode Island

Rhode Island's (RI) CHOICES program (Citizenship, Health, Opportunities, Interdependence, Choices, Environments, Supports) uses an integrated health/medical (acute care) and community supports (long-term care) approach to providing home and community-based services. CHOICES uses principles of managed care to give adults with developmental disabilities a greater role in designing and purchasing health and community support services. The process emphasizes:

  • Personal needs.
  • Consumer's profile and preferences.
  • Health and safety risks.
  • Rights and responsibilities.
  • Natural supports.
  • Satisfaction and outcome indicators.
  • Identification of providers of service and support.

The RI Division of Developmental Disabilities supports a population of 3,500 adults with developmental disabilities and has closed all of its institutions for this population. The current value-based system promotes choice, empowerment, and equitable access to resources and information for people with disabilities.

Access to services is determined by eligibility determination staff. Once eligible, consumers are assigned a community support worker or social worker who completes a personal-capacities inventory and situational assessment instrument to determine service needs and funding requirements. These tools, coupled with the following, make RI's CHOICES program a success:

  • A choice of natural supports.
  • Service providers.
  • Individualized treatment plans.
  • The implementation of services.

Person-centered planning is seen as the key to achieving quality of life. Consumers who have more creative things to do during the day have better knowledge of the services and options that are available to them. Also, their personal expectations seem to be greater than those who may not have access to creative options. RI added resources to help program participants identify service options:

  • Self-advocates.
  • Family advocacy programs.
  • Social services.
  • Trade shows.
  • Community networking.
  • Written information.

The program promotes independence through personal control and relationships. By knowing the availability of services and establishing relationships with friends and family, the community, and professional organizations, the individual in turn gains more personal control. With this personal control comes the acquisition of information, resources, and opportunities.

The Division of Developmental Disabilities carries out its monitoring and oversight through internal and external mechanisms:

  • Individual service records.
  • Review of health and safety standards.
  • Check of provider qualifications.
  • Fiscal accountability.
  • Provision of quality improvement.
  • Reauthorization of funding level.


Wyoming has implemented the DOORS program to create individual budgets, based on consumer needs, and to serve adults and children with developmental disabilities in community settings. The program is being phased in as home and community-based waiver service plans are reassessed. One goal of the program is to shift decisionmaking from central offices to the local level. The system sets Individual Reimbursement Amounts (IRAs) for service plans.

Although the program was not implemented as a formal self-determination initiative, IRAs are grounded in the fundamental principles of self-determination and consumer direction. The program was developed to rationalize the allocation of resources and service plans. It is too early to determine the extent to which the changeover to IRAs is leading to significant modifications in services and/or the providers that individuals and families are selecting. It has been a long-standing policy in Wyoming that individuals be able to exercise free choice of provider.

The model was developed using multiple regression analysis to reduce the variance in resource allocations. The Division staff identified multiple factors that might influence service need. Factors were included or excluded based on their predictive influence. In the case of adult home and community-based waiver participants, the factors explained 51 percent of the variance in current resource allocation levels. In other words, there was a significant residual or unexplained variance in resource allocations that arose from factors other than the ones selected by State officials.

The development of the adult model went through nine iterations before it was finalized. In the first iteration, 40 variables were included. Where a consumer characteristic was included, but its correlation with costs ran in an unexpected direction (i.e., "face validity" was violated), the variable was thrown out. Other variables were also discarded to the extent that they did not contribute to reducing the amount of unexplained variance.

In the case of both the adult and children's DOORS models, the formulas that were developed describe the best statistical fit between existing resource allocations.

The models statistically describe the resource allocations that would result if all the various factors were taken into account in a consistent fashion for all individuals served. The effect on resource allocations of other factors that were excluded from the models was reduced or eliminated.

The DOORS model does not describe the causes of differences in the costs of supporting individuals. Explanation of variance methods can be applied to normalize data against any of a wide variety of factors. The statistical analysis that underlies the DOORS models normalized funding on a person-by-person basis against the factors that State officials believed should serve as a legitimate basis for individual resource allocations.

The DOORS model is based on statistical analysis that normalizes resource allocations by taking into account:

  • Services that have been determined as needed during service planning.
  • Various consumer characteristics.
  • In the case of the adult model, economic and provider measures to generate resource allocations on a formula basis.

This formula ensures such resource allocations will be determined uniformly. The statistical methods used aid in sorting out the various factors and assigning proper weights to each.

The initial implementation has been received favorably:

  • DOORS appears to enjoy broad stakeholder acceptance.
  • The system is perceived to be fair and equitable.
  • It informs individuals and families of the amount available in clear terms.
  • It has reduced the suspicion that individuals and families have been treated differently or that some providers have secured more favorable payments than others have.

Additional Resources

Lakin KC. Research and Training Center on Community Living, Minneapolis, MN. Medicaid home and community-based services for persons with developmental disabilities in Wyoming. Fairfax (VA): The Lewin Group;2000 May.

Mission statement. Providence (RI): State of Rhode Island, Division of Developmental Disabilities;2001 Jul.

Rhoades JA, Altman BM. Personal characteristics and contextual factors associated with mental retardation. Am Assoc on Ment Retard 2001 Apr; 39(2):114-29.

Smith G. Wyoming DOORS: Setting individual resource allocations for HCB services. Alexandria (VA): National Association of State Directors of Developmental Disabilities Services, Inc.;1999 Feb.

Wyoming's person-centered system architecture. Cheyenne (WY): State of Wyoming, Division of Developmental Disabilitites;2001.

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