Andrew M. Cuomo Governor Courtney Burke Commissioner
New York State Oﬃce For People With Developmental Disabilities
Statewide Comprehensive Plan
PEOPLE WITH DE VE OR LO EF IC
DISABILITIES TAL EN PM
NEW YORK STAT EO FF
G PE O PLE
October 1, 2012
Table of Contents Mission, Vision, Values, and Guiding Principles…………………………….........................2 Stakeholder Engagement………………………………………………………………………….4 Environment for Change…………………………………………………………………………..6 Olmstead Affordable Care Act Medicaid Redesign Budget/Service Demands Quality Oversight
System Transformation……………………………………………………………………………11 Cultural Change Initiative OPWDD Reorganization
Putting People First………………………………………………………………………………..14 People First W aiver People First W aiver Case Studies Developmental Disabilities Individual Support and Care Coordination Organization (DISCO) Pilots Dual Eligible Individuals Demonstration Individual and Community Supports (ICS) and the Front Door
Implementing the Mission and Vision…………………………………………………………..23 Home Developmental Center Closures Housing Initiatives
Health and Safety Health and Safety Reforms Systemic, Therapeutic, Assessment, Respite, and Treatment (START)
Relationships Positive Relationships Offer More Opportunities to Everyone (PROMOTE) Workforce Initiatives
Employment and Meaningful Activities Employment First Initiatives Community Service Initiative Monthly Community Habilitation Faith-based Initiative
Conclusion…………………………………………………………………………………………..37 Appendix A: Summary of 2013 County Plans………………………………………………....38
Dear Friends and Colleagues: I am pleased to share with you the New York State Office for People W ith Developmental Disabilities’ (OPWDD) Statewide Comprehensive Plan for 2012-2016. The plan describes OPW DD’s strategic direction for carefully and methodically shifting New York’s developmental disabilities service delivery system to managed care through the implementation of the People First W aiver. The People First W aiver is significant because New York State will be one of the first states to combine long-term care, physical health and mental health services into a 1915 b/c waiver that will address all the needs of people with developmental disabilities. OPWDD is poised to submit waiver applications and/or waiver amendments to the federal Centers for Medicare & Medicaid Services (CMS) this spring and anticipates having approved agreements by fall 2013. In addition to our efforts to plan and implement the People First W aiver, OPWDD continues to make progress on system reforms, and implement new approaches to delivering services and supports within our existing Home and Community Based Services (HCBS) waiver. Some of our most recent accomplishments are: • •
• • • •
Reduced the number of people with developmental disabilities who live in institutional settings to just over 1,000 people and through the People First W aiver the census will drop even more significantly. Received 1.8 million dollars through the Governor’s Medicaid Redesign Team’s (MRT) Supportive Housing Development Program, which will increase the number of affordable, integrated, and accessible housing opportunities. Implemented Phase II of Community Habilitation so individuals experience greater choice over the meaningful activities that they engage in. Improving access to individualized services through the development of a new front door and Individualized Community Services (ICS). Creating a culture of transparency and accountability by posting provider performance report cards on the OPWDD website. Centralized the oversight of serious incidents and allegations of abuse to safeguard individuals with developmental disabilities.
System transformation is not easy and requires the help of people beyond the exceptional staff at OPW DD. I want to thank the many stakeholders involved on the People First W aiver work teams, the individuals, family members, and advocates who provided input at public engagement events, and voluntary providers that promoted individualized services through the innovative ideas workshops and on other various committees and councils. Together, we have made significant progress and I look forward to our continued partnership in designing a service delivery system that is equitable, sustainable, and accessible to New Yorkers with developmental disabilities and their families. Sincerely,
Courtney Burke Commissioner Executive Office 44 Holland Avenue, Albany, NY 12229-0001, TEL: 518-473-1997 FAX: 518-473-1271 75 Morton Street, New York, NY 10014, TEL: 212-229-3231 FAX: 212-229-3234 101 West Liberty Street, Rome, NY 13440, TEL: 315-336-2300 x246 FAX: 315-571-7118 500 A Balltown Road, Schenectady, NY 12304 TEL: 518-381-2110 FAX: 518-381-2190 TTY: 866-933-4889, www.opwdd.ny.gov
We help people with developmental disabilities live richer lives
Mission, Vision, Values, and Guiding Principles Mission We help people with developmental disabilities live richer lives.
Vision People with developmental disabilities enjoy meaningful relationships with friends, family, and others in their lives, experience personal health and growth, live in the home of their choice, and fully participate in their communities. OPWDD is committed to achieving five basic outcomes for people with developmental disabilities: •
Person First – Individuals with developmental disabilities have plans, supports, and services that are person-centered and as self-directed as they choose.
Home of Choice – Individuals with developmental disabilities are living in the home of their choice.
Work and Meaningful Activities – Individuals with developmental disabilities are able to work at paying jobs and/or participate in their communities through meaningful activities.
Relationships – Individuals with developmental disabilities have meaningful relationships with friends, family, and others of their choice.
Health and Safety – People with developmental disabilities experience good health and are safe in their home and community.
Values Compassion – The capacity to appreciate what others think and feel. Dignity – The recognition of the worth of each person and the treatment of individual rights and preferences with respect, honor, and fairness. Diversity – The celebration, respect, and embracing of the differences among us, because these differences strengthen and define us. Excellence – The continual emphasis on innovation, increasing knowledge, and delivering the highest quality supports and services. Honesty – The foundation on which trust is built and truth is communicated.
OPWDD’s Guiding Principles Put the Person First – People with developmental disabilities are the heart of everything we do, and this person-first ethic is embodied in the way we express ourselves and in the way we conduct business. Maximize Opportunities – OPWDD’s vision of productive and fulfilling lives for people with developmental disabilities is achieved by creating opportunities and supporting people in ways that allow for as many as possible to access the supports and services they want and need. Promote and Reward Excellence – Quality and excellence are highly valued aspects of our services. We find ways to encourage quality, and create ways to recognize and incentivize excellence to improve outcomes throughout our system. Provide Equity of Access – Access to supports and services is fair and equitable; a range of options is available in local communities to ensure this access, regardless of where in New York State someone resides. Nurture Partnerships and Collaborations – Meaningful participation by people with developmental disabilities strengthens us. OPWDD staff and stakeholders create mechanisms to foster this participation. The diverse needs of people with developmental disabilities are best met in collaboration with the many local and statewide entities that are partners in planning for and meeting these needs, such as people who have developmental disabilities, families, nonprofit providers, communities, local government, and social, health, and educational systems. Require Accountability and Responsibility – There is a shared accountability and responsibility among all stakeholders, including individuals with developmental disabilities, their families, and the public and private sector. OPWDD and our providers are held to a high degree of accountability in how they carry out their responsibilities. We strive to earn and keep the individual trust of people with developmental disabilities and their families, as well as the public trust. Creating a system of supports that honors the individual’s right to be responsible for their own life and accountable for their own decisions is of paramount importance.
Stakeholder Engagement OPWDD recognizes that continuous public engagement is an essential element of strategic planning. The quality of the People First Waiver and its impact on the provision of habilitative supports and services is dependent upon feedback from all New Yorkers involved in the developmental disability system. As a result, senior management within the organization regularly meet with the Commissioner’s Developmental Disabilities Advisory Council, individuals with developmental disabilities, self-advocates, other advocates, family members, provider associations, county directors, voluntary provider agencies, and other interested parties to ascertain how federal, state, and local policies and procedures affect people with developmental disabilities. Outcomes from stakeholder engagement are incorporated into the agency’s statewide comprehensive plan for service delivery. Traditionally, OPWDD engaged stakeholder groups through formal face-to-face meetings and forums, and recently expanded its presence on the Internet though social media outlets such as YouTube and Facebook. Figure 1 highlights the mediums OPWDD uses to encourage a continuous dialogue with the public. Figure 1. Stakeholder Engagement • DD Advisory Council • Provider associations • County DD subcommittee • Family Support & Services Committee
• Facebook • YouTube • People First Waiver webpage
Committees & Councils
Internet & Social Media
Newsletters & Listservs
Public Forums & Hearings
• Commissioner's correspondence • OPWDD newsletter • Waiver communications • People First mailbox
• People First Waiver forums/briefings • 5.07 hearing • Olmstead hearings
Ongoing communications, whether face-to-face or online, help New York State shape the People First Waiver and the many system reforms it will bring. In April 2012, OPWDD held a series of public briefings to update the public on the waiver, answer questions, and gather further input. People First Waiver liaisons from regional offices also began meeting with groups of stakeholders around the state for the same purpose. In spring 2012, OPWDD held innovative ideas workshops that showcased how providers are working together for improved efficiencies and outcomes for the people they support. Guidance and oversight of the People First Waiver and its development and implementation recently transitioned from the steering committee to the standing Developmental Disabilities Advisory Council. 4
The goal of OPWDD’s public engagement efforts is to maintain an open line of communication with key stakeholders and use their feedback to continuously improve the quality of service delivery and plan for the future development of the People First Waiver.
Environment for Change In addition to gathering feedback from stakeholders, OPWDD also scans the federal, state, and local environment for regulations, policies, and other changes that will potentially impact services for individuals with developmental disabilities. Although many factors contribute to the transition to managed care and systemic reform, five state and/or federal policy decisions significantly influence the current operating environment and strategic direction: 1. 2. 3. 4. 5.
Olmstead decision; Affordable Care Act; Medicaid redesign; Budget/service demands; and Quality oversight.
Olmstead Decision The 1999 U.S. Supreme Court ruling in the landmark case of Olmstead v. L.C. held that unnecessary institutionalization of individuals with disabilities violates the Americans with Disabilities Act (ADA). The ruling found that individuals should be allowed to receive services and supports in the most integrated setting appropriate to their needs. Olmstead vs. L.C. was initiated on behalf of two individuals in Georgia who were confined in a state psychiatric hospital long after their treatment team had recommended they could be served effectively in the community. Their unnecessary institutionalization was interpreted as discrimination by reason of disability. To meet their obligations under the ADA, states must demonstrate they have an effective plan to transition eligible individuals with developmental disabilities to integrated community settings. Early in his tenure, Governor Andrew M. Cuomo reiterated his commitment to civil rights and the ADA in his State of the State address in January 2012 when he charged his agency commissioners to develop an Olmstead Plan.
“As the Supreme Court ruled in Olmstead v. L.C., people with disabilities have the right to receive care in the most integrated setting appropriate to their needs. Therefore, we will develop an Olmstead implementation plan that will guide the transition of individuals from institutional to community-based care, provide access to affordable and accessible housing, and promote employment of persons with disabilities. We must erase stigmas and ensure that the rights of people with disabilities are fully recognized and fully protected.” —Governor Andrew M. Cuomo
As a first step, OPWDD is working with Governor’s Cuomo’s office and the other state health and human service agencies to gather input from the public and develop a comprehensive plan for providing services and supports in the most integrated setting. In late summer and early fall of 2012, Governor Cuomo sponsored four public hearings to solicit information from people with disabilities and other stakeholders. Testimony from the public hearings is being analyzed and will be used to develop the outline and content of the Olmstead Plan. Preliminarily, the outcomes from the hearings have been summarized into a few target areas for the developmental disability system. To support consistency with the Olmstead Decision, OPWDD supports: • •
• • • •
Transitioning individuals residing in developmental centers to community-based settings by 2014; Preventing institutionalization by helping individuals access community-based supports and services, including, but not limited to, community habilitation, care coordination, behavioral interventions, environmental modifications, and adaptive equipment; Creating a valid and reliable assessment process to determine the appropriate level of support and funding individuals need to live and work in the community; Increasing the number of individuals employed in integrated settings and earning minimum wage or higher; Developing affordable, accessible, and integrated housing opportunities with the appropriate level of support needed for individuals; and Collaborating with other state and local systems to address transportation barriers in rural, suburban, and urban settings.
New York State will further refine its goals and strategies, and then publish the final comprehensive, working Olmstead Plan by May 2013. At the federal level, the Olmstead Decision and the ADA set the policy direction for all state governments to serve qualified individuals with disabilities in the most integrated setting appropriate to their needs. OPWDD is committed to achieving this outcome with the People First Waiver being the vehicle for state change. Affordable Care Act As the Olmstead Decision conceptualizes how states should best serve individuals with disabilities, the Affordable Care Act establishes new policies and incentives for states to expand access to Medicaid Home and Community Based (HCBS) Services programs. On March 23, 2010, President Obama signed comprehensive health reform: the Patient Protection and Affordable Care Act, into law. The ACA contains provisions to expand coverage, control health care costs, and improve the health care delivery system. This legislation will impact all Americans, including individuals with developmental disabilities. Specifically, individuals with disabilities in New York State will benefit from the following reforms and protections: • • • •
Health coverage for all individuals regardless of disability or pre-existing conditions; Prohibits annual coverage limits in health plans and insurance policies; Requires health benefit plans to include rehabilitative and habilitative services and devices as covered benefits; Expands Medicaid eligibility to 138% of the federal poverty level (approximately $30,000 per year for a family of four); 7
• • •
Creates a temporary 90% federal match for states to provide health homes for individuals with chronic conditions; Provides states with the option to expand community-based attendant services through Community First Choice (CFC); and Extends the Money Follows the Person (MFP) rebalancing demonstration through September 30, 2016.
The ACA will help many individuals with developmental disabilities receive better coverage through the private insurance industry. In addition, the New York State Department of Health (DOH) is participating in the Community First Choice option, which will expand participant directed and agency-based attendant care supports as part of the Medicaid state plan. OPWDD is participating in the development of CFC, which will be a viable alternative to institutional settings for seniors and people with disabilities. Medicaid Redesign Governor Andrew M. Cuomo established the Medicaid Redesign Team (MRT) by executive order upon taking office in January 2011, bringing together stakeholders and experts from throughout the state to work cooperatively to reform the Medicaid system and reduce costs. The most significant aspect of this initiative is the transition of all Medicaid programs to managed care, resulting in New York State pursuing the People First Waiver. In addition, the Governor’s MRT identified supportive housing as one of its priorities. In March 2012, the Governor’s budget established and funded a new supportive housing development program that provides service funding, rent subsidies, and capital dollars to create supportive housing for Medicaid recipients . OPWDD was awarded $1.8 million for this effort. More information about this program is discussed in the housing section. Budget/Service Demands Many people with developmental disabilities are living longer to the point where lifespans are nearly comparable to that of the general population. Analyses conducted at OPWDD demonstrate that the proportion of individuals with multi-system and complex health needs is growing and will continue to grow well into the future. Individuals seeking services are increasingly likely to have a dual diagnosis (30%), autism spectrum disorder (20%), and two or more medical conditions (20%). Statewide, OPWDD is also noticing growth in federally recognized racial/ethnic minority groups accessing services (36%), illustrating the need for providers to become increasingly culturally and linguistically competent. As the demographics of individuals in New York State change, so do their requests for specific service and support models. People with developmental disabilities and their families are increasingly seeking more individualized services that provide supports in their own home and promote community participation. Currently, over 80% of OPWDD’s community funding is tied
to certified residential and day services, which occur in congregate settings. Given the high proportion of funding associated with group-based, residential, and day services will play a central role in efforts to contain growth in future expenditures. Efficient and effective models of care that continue to meet individual’s needs must be promoted. OPWDD outlines strategies in the People First Waiver section of this report to expand individualized services and ensure the fiscal health and long-term longevity of the developmental disabilities service system. Quality Oversight OPWDD continues to implement quality oversight reforms to improve the quality of supports and services provided to individuals with developmental disabilities. Quality improvement is not a single goal that is achieved at one specific point in time, but a process of implementing change, monitoring outcomes, and then addressing issues as they arise. OPWDD follows the Centers for Medicare & Medicaid Services’ (CMS) model for continuous quality improvement (CQI) for HCBS waivers, as shown in Figure 2. Figure 2. Continuous Quality Improvement Model
The CQI model is used for OPWDD’s existing HCBS waiver and will be adopted as the quality improvement framework for the People First Waiver. CQI uses empirical data to propagate continuous improvement in a cyclical fashion. This model has been used in various sectors, including health and human services. The CQI process is as follows: first, OPWDD designs a plan to monitor the quality of the services and supports provided to individuals with developmental disabilities. Next, staff engage in a discovery process to examine the efficacy of the service delivery system through
the use of quantitative data. Then, based on the data collected and staff observations, OPWDD determines which aspects of the system require remediation or correction. Finally, the agency implements improvements to the developmental disabilities “The Justice Center for the system to ensure people are healthy, safe, and receive Protection of People with quality supports and services. CQI allows for consistent, Special Needs will give New ongoing monitoring of service delivery practices in New York York State the strongest State, with a focus on improving quality of life for individuals standards and practices in the with developmental disabilities. nation for protecting those who In addition to CQI, OPWDD has been participating in are often the most vulnerable statewide, interagency quality oversight initiatives including to abuse and mistreatment.” working diligently to prepare for the implementation of the Justice Center and other changes necessary to conform with – Governor Cuomo this historic piece of legislation taking effect on June 30, 2013.
System Transformation Cultural Change Initiative The initiative to reshape the culture of OPWDD and the state’s developmental disabilities system began in earnest in fall 2011 with the creation of a workgroup comprised of leaders from state and voluntary agencies, self-advocates, families, and direct support professionals. Culture is defined as a shared set of attitudes, values, goals, and practices that characterize the developmental disabilities system. The attributes of culture that OPWDD is seeking to develop throughout the statewide system are: • • • • •
Strong, committed, and caring; High-performing and based on the agency’s core values of compassion, dignity, diversity, excellence, and honesty; Fostering relationships based on trust and confidence in the service system; Creating a learning environment of ongoing assessment and improvement; and Providing clear understanding to all members of the service delivery system of their roles and responsibilities in building and sustaining this culture.
Creating lasting changes in culture requires an alignment of organizational values and policies, as well as alignment of personal values held by employees throughout the system. To support the creation of the desired culture, OPWDD is undertaking initiatives spanning four major areas: leadership’s decision-making, policy, and structure; workforce and talent development; work processes and systems; and quality improvement. As of summer 2012, the workgroup defined goals and focus areas for multiple agency initiatives. These include: OPWDD’s adoption of the National Alliance for Direct Support Professionals’ Code of Ethics; core competencies for DSPs, and core competencies for DSP supervisors in progress; a new system-wide standard for service provision called Positive Relationships Offer More Opportunities to Everyone (PROMOTE) that focuses on positive approaches to supporting individuals, including behavior intervention and a reduction in use of physical restraints; a shift to a person-centered service delivery model under the People First Waiver; an agency reorganization to create consistency in practice and maximize efficiency; and improved service delivery. OPWDD is implementing these initiatives in a coordinated manner to serve as levers to shape culture and the statewide system of supports. OPWDD Reorganization The goal of OPWDD’s reorganization is to implement a consistent approach and culture to all developmental disabilities services (whether provided by the state or voluntary agencies) so that any individual who receives supports can expect the same quality and positive environment no matter what they need, where they are located, or which agency supports them. The developmental disabilities services offices (DDSOs) were formed in 1978 to create regions that focused on transitioning large campus populations into community settings. By 1995, nine developmental centers had closed, and the original 20 DDSOs were consolidated to 13. This structure was in effect until OPWDD reorganized in July 2012.
In OPWDD’s new organizational structure, the oversight of voluntary providers and state operations is divided into two distinct but coordinated offices, state operations offices and regional offices, under the Division of Service Delivery. Five regional offices are responsible for overseeing voluntary agency coordination and monitoring. Because voluntary agencies account for approximately 80% of OPWDD’s service provision, it was important for regional offices to focus on this segment of the system. The catchment areas of the regional offices were established to improve oversight and quality improvement, as well as to allow for cross system collaboration among State agencies. Figure 3 shows the five developmental disabilities regional offices (ROs). Figure 3. Regional Offices
OPWDD reorganized its state operated programs into six state operations offices (SOOs). The sole responsibility of the SOOs is the operation and oversight of residential, day service, clinic, and other programs for which New York State is the direct provider of service or provider of record. The six state operations offices combine the former DDSO catchment areas into the following model shown in Figure 4.
Figure 4. State Operations Offices
The purpose of the reorganization was to bring a clearer focus to these two important and distinct aspects of OPWDD’s service system. For decades, the DDSO directors assumed responsibility for state-operated supports, in addition to local operations, which included all local administrative and support functions (e.g., safety/security, maintenance, human resources, business office operations, staff development and training, and IT), as well as local voluntary agency provider development and coordination. This diverse set of duties was challenging to manage under the DDSO model. The new framework will provide a consistent approach and culture, so that individuals and their families can expect quality in all services delivered by OPWDD and its voluntary provider partners.
Putting People First People First Waiver In the summer of 2012, OPWDD entered into the implementation planning stage to finalize the People First Waiver application and carefully map the transition to managed care. The agency established targeted work teams composed of individuals with developmental disabilities, family members, providers, and local government units to focus on three key design areas of the new service delivery system: 1) access, enrollment, and advocacy; 2) care coordination; and 3) modernizing the fiscal platform. The access, enrollment, and advocacy work team recommended policies and procedures for the pilot managed care organizations known as developmental disability individual support and care organizations (DISCOs) that will: •
Ensure DISCOs inform people with developmental disabilities about their individual rights as DISCO enrollees, including rights related to the grievance and appeals process; Evaluate grievance and appeals practices at DISCOs to ensure effective enrollee due process protections; and Provide individuals with access to strong independent advocacy.
The care coordination work team developed quality measures in collaboration with Delmarva, a consultant group with experience in formulating quality outcomes in other states, and outlined the parameters for a customized and integrated care management/care coordination system that employs person-centered planning to support the full range of service needs for people with developmental disabilities. The team made recommendations regarding: • • •
Required qualifications and core competencies for the lead care coordinator; Quality outcome measures for care coordination; and Person-centered planning, documentation, training, and supervision.
The modernizing the fiscal platform team was charged with providing a foundation for a new rate reimbursement system that will promote equity, sustainability, alignment of the financial platform, and incentives for desired service and system outcomes for people with developmental disabilities. The fiscal platform team agreed that OPWDD’s rate reform should follow a component-based approach that examines cost patterns for various rate components (e.g., program support, general and administrative costs) as they relate to the direct care staff wage. This approach is used to establish the total cost of a direct staff hour, and then to determine standard fees according to the number of staff hours needed to meet an individual’s needs. This method of standardized rate development, based on the direct care staff driven model has been used in other states. OPWDD has engaged consultants that are experienced in this approach both for long-term care programs and for developmental disabilities services. It is OPWDD’s intent that the new methodology will be implemented in the fee-for-service delivery system and also used in the development of a capitation fee within managed care.
The targeted work teams of the People First Waiver completed their work in fall 2012. OPWDD posted their final recommendations of the work teams on the People First Waiver webpage: www.opwdd.ny.gov/opwdd_services_supports/people_first_waiver/targeted_work_teams. Key elements of the work teams’ recommendations will be incorporated with revisions to the draft request for applications (RFA) that will be submitted to the federal Centers for Medicare & Medicaid Services (CMS) as part of the 1915 b/c People First Waiver applications. Working with the New York State Department of Health, OPWDD expects to submit the draft DISCO contract to CMS in January 2013 and anticipates final approval by September 2013. Once the applications are submitted, OPWDD will post links to the CMS website, where stakeholders can access the waiver applications and provide formal comments. Figure 5 shows the timeline for the implementation of the People First Waiver through 2015. Figure 5. People First Waiver Timeline January 2013
•Submit draft •Issue DISCO DISCO contract request For and revised RFA application to CMS and share with stakeholders
July – August 2013
•Conduct DISCO •Select pilot •Issue DISCO •Begin DISCOs readiness certificates of enrollment into review pilot DISCOs •CMS approval authority •Execute of DISCO •CMS approval informational of B/C waiver contract outreach to •Finalization of agreements stakeholders DISCO capitated rates
2015 •Post RFA for statewide rollout of comprehensive care DISCOs •Begin mandatory enrollment into DISCOs •Plans begin transition to fully integrated care models
To help service providers prepare for system reforms, OPWDD posted a draft of the RFA for informational purposes only on its People First Waiver webpage (www.opwdd.ny.gov/opwdd_services_supports/people_first_waiver/home) for DISCOs. People First Waiver Case Studies From November 1, 2012 through December 31, 2013, the People First Waiver case studies will enable OPWDD and its provider network to pilot key system reforms before moving to a managed care environment. By focusing on small pilot projects, OPWDD and its participating providers will gain valuable experience to help the transition to a managed care delivery system that addresses the unique needs of people with developmental disabilities. The design of the case studies will concentrate on three major areas: 1. Assessment: OPWDD will test the tools, processes, and results of the coordinated assessment system (CAS). The CAS will be built from the InterRAI assessment suite, which can predict individual support needs and convert assessment information into an individual life plan (i.e., care plan). The life plan identifies personal goals and health and safety supports needed by the person.
2. Translate flexible financing (within existing authority and resources) to demand oriented, innovative support models: OPWDD will use existing resources to flexibly fund innovative services and supports based on what people with developmental disabilities really need and want. The case study utilizes current support options within the 1915(c) waiver to maximize access to self-directed supports. In addition, it will provide an important learning opportunity for providers to develop strategies that support personal outcomes while transitioning to a funding structure that is equitable and needsbased. 3. Individual outcome measures and quality performance: OPWDD will develop and pilot new approaches to assess provider performance, an indicator of quality in developmental disabilities systems. This approach incorporates the InterRAI, personcentered life plan outcomes and case study documentation, the National Core Indicators (NCI) consumer survey, and other tools that measure the extent to which providers are helping people with developmental disabilities identify and accomplish their individual outcomes. To test these concepts, OPWDD will work with voluntary agencies that have been identified as exceeding minimum quality standards through special accreditation as a Compass agency or that have practices consistent with these standards, by completing focused studies that gather data about several key areas where change is needed and/or anticipated. Figure 6 shows the providers that are participating in the case studies. Figure 6. Case Study Agencies
•Franziska Racker Centers
•Herkimer Area Resource Center •ARC of Onondaga
•Heritage Christian Services •Finger Lakes UCP • Chemung ARC
•Hamaspik of Rockland County •Hawthorne Foundation, Inc. •Occupations, Inc. •Opengate, Inc.
•Women's League •Independent Residences, Inc. •HeartShare
•Anderson Center for Autism
•Claddagh •People, Inc. •Rivershore •Suburban Adult Services, Inc.
In addition, OPWDD is partnering with other stakeholders to gain objective input into both the design and lessons learned from the studies. The following organizations will help test some of the key elements in the case studies:
Westchester Institute for Human Development (WIHD): WIHD created an iPad application to measure consumer satisfaction and individual outcomes largely based on NCI criteria. The application is interactive so individuals with disabilities can provide responses to survey questions with minimal assistance from a proxy. WIHD is refining the application so it can be tested with case study participants.
Self-Advocacy Association of New York State (SANYS): SANYS will work with WIHD to facilitate the use of the iPad application by individuals receiving services. Selfadvocates will provide instruction on the application for independent use of the iPad or work with the person to give direct assistance, if needed.
Council on Quality and Leadership (CQL): CQL will provide training about determining personal outcome measures for people participating in the studies. The training and personal outcome measure (POM) workshops will be for representatives from participating agencies, families, and OPWDD’s Division of Quality Improvement (DQI) and other staff. The approaches in the CQL curriculum are evidence-based and used nationally as appropriate measures of assessing outcomes for people with developmental disabilities.
New York State Developmental Disabilities Planning Council (DDPC): DDPC will work with OPWDD to monitor and provide feedback on the joint quality activities during the case studies. Through DDPC support, OPWDD will involve family representatives in the CQL POM workshops.
InterRAI: OPWDD is partnering with InterRAI, an international consortium of assessment developers, to create a core assessment instrument with appropriate supplemental tools to quantify the needs of individuals receiving supports and services. The CAS will be utilized in the case studies and surveys related to the process and adequacy of information will be conducted. The information collected (related to both the assessment process and the tools) during the case studies will be reviewed by InterRAI and OPWDD for feedback on changes needed to achieve a comprehensive and person- centered assessment system.
Case Study Participants A group of individuals now served by providers in the general case study will be selected as focused case study participants. The focused case study participants are aligned in the following categories: • • •
Individuals with developmental disability profiles (DDPs) that indicate they have independent skills and are living in a 24/7 certified residential setting. Individuals with DDPs that indicate high behavioral needs, but are receiving few to no OPWDD services. Individuals identified by case study provider agencies as wanting alternative supports such as increased self-direction, intensive employment services, and other alternative models of support.
The participating providers serve a total of 12,800 people. OPWDD estimates that there will be approximately 4,700 individuals in the general case study, and of these, approximately 1,000 will participate in the focused case studies. OPWDD has selected 750 people to participate in the two focused case study groups based on the DDP analysis and will select an additional 250 case study participants who request alternative supports. Case Study Learning Objectives The success of People First reforms is predicated on building an innovative and flexible infrastructure that supports the diversity of all individuals with developmental disabilities. This infrastructure must perpetuate care coordination practices that are effective across a variety of living environments; be based on evidence-based clinical practices, utilize person-centered innovative models of support with flexible funding; and employ quality measures that tie to personal outcomes. OPWDD hopes to meet the following learning objectives as a result of implementing the case studies: 1. Assessment: • How well the assessment process and tools were able to predict individual support needs and translate them into an effective person-centered life plan with measurable individual outcomes. • Best practices for efficiency and inter-rater reliability of the assessment process. • Best practices for conducting the assessment with the least amount of intrusiveness with the involved parties (people being assessed, family, and support givers). • Best practices to ensure that assessment specialists have sufficient input into the process and that providers receive sufficient information to develop a comprehensive person-centered plan. • Delineation of the training needs and qualifications to successfully utilize the InterRAI. 2. Translate flexible financing (within existing authority and resources) to demand oriented, innovative support models: • Identification of planning approaches and innovative strategies and support models in a self-directed environment. • Whether individuals accessed different community-based housing support models. • Whether individuals in 24/7 certified housing models were able to transition to more integrated settings. •
Whether service changes led to better outcomes and increased individual satisfaction.
3. Individual outcome measures and quality: • •
How well each provider met individual needs and desired outcomes. Whether the case study care plan and service documentation capture an individual’s needs and identify the person’s outcomes for accurate quality review. How individual quality measurement can translate into a core set of specialized managed care quality performance measures specifically for people with developmental disabilities.
DISCO Pilots OPWDD is committed to the mission of helping people live richer lives and creating stronger person-centered services now and in the future for individuals with developmental disabilities. Over a two-year period, OPWDD, with the support and oversight of DOH, will pilot specialized managed care organizations that meet the applicable requirements of Article 44 of the Public Health Law and have expertise in the provision of services under the auspice of OPWDD. As previously mentioned, these new entities, charged with coordinating comprehensive supports and services under new Medicaid funding agreements with the federal government (referred to collectively as the People First Waiver) will be known as developmental disabilities individual supports and care coordination organizations (DISCOs). Key elements of DISCOs will include: • Receiving funds, providing person-centered planning, coordination of services, and ensuring delivery of high quality services. • Funding to the DISCO will be based on an individual’s needs, not allocated based on general service categories. • Managing per-member-per-month funds to meet the needs of all their members. • No limit for spending on any individual—the capitated rate (i.e., specific payment made to the DISCO as designated by Medicaid) will not mean limited services. An individual must have a service plan that meets his or her needs, regardless of cost. During the pilot period, individuals will voluntarily opt to enroll in the pilot DISCO. In keeping with the programmatic objectives of the People First Waiver, the DISCO will be required to describe how it will: • • • •
Provide person-centered planning for all individuals enrolled in the DISCO; Promote living and active engagement in the most integrated setting; Ensure that each individual who chooses to do so can self-direct his or her services, including the option for budget and employer authority; and Promote paid employment for individuals enrolled in the DISCO.
The application process will begin in 2013 and will include a letter of intent, a formal application, and a final readiness review that ensures that the DISCO is ready to begin coordinating services. In order to be eligible to become a DISCO, an applicant must be a public or nonprofit (private) entity incorporated under New York State Law and have at least 10 years’ experience coordinating care for individuals with intellectual/developmental disabilities. Experience coordinating care for individuals with developmental disabilities will be evaluated based on the average number of years of experience of the DISCO’s board members and officers in overseeing and operating entities that deliver Medicaid service coordination or HCBS waiver services, and are in good standing with OPWDD. The DISCO and all network providers with which it subcontracts will be in compliance with all applicable state and federal licensing, certification, and other requirements. These entities must be generally regarded as having a good reputation and have demonstrated capacity to perform needed services. The DISCO must maintain an administrative and organizational structure that supports high quality supports and services through comprehensive care coordination. The management structure should ensure effective linkages among administrative areas: quality management; 19
network development and contracts management; information technology (i.e., utilization review); enrollment/disenrollment; care coordination; accounts receivable/accounts payable; and budget, finance, and accounting. A complete description of a DISCO’s areas of responsibility will be identified in its contract with New York State. Key elements of the transition to managed care service delivery include: • • • • • •
Protecting due process rights and independent advocacy. DISCOs will be required to serve people with all levels of service need—no DISCO may drop people with higher service costs. Everyone will have a choice of providers within their DISCO. Every person will have the option to self-direct an individualized service budget with the appropriate level of support. Transition to a managed care service system across the state will take place slowly over many years and begin with carefully constructed and evaluated pilot DISCOs. OPWDD will ensure that people can continue to use their current service providers during DISCO rollout.
Dual Eligible Individuals Demonstration New York State DOH’s duals demonstration is a proposed initiative to coordinate Medicare- and Medicaid-funded physical health care, behavioral health care, and long-term supports and services. A limited number of individuals (up to 10,000) with developmental disabilities will have the option to voluntarily participate in this demonstration. OPWDD participation will occur in two phases: •
Phase 1: Starting in July 2013, OPWDD, working through DOH, will approve up to three managed long-term care plans (MLTCPs) to provide non-OPWDD long-term supports and services (e.g., personal care, adult day care, etc.).
Phase 2: Starting in January 2014, these plans will transition to Fully Integrated Duals Advantage (FIDA) programs that will provide comprehensive services and supports (i.e., OPWDD long-term supports, health care, behavioral health care, and the Phase One long-term supports).
The demonstration will allow OPWDD to begin operating a comprehensive managed care model on a small scale prior to statewide transition. The demonstration application and additional information about submitting public comment on the proposal may be found at: www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/dual_demo_propos al_to_cms.htm. Individual and Community Supports and the Front Door The Individualized Services Workgroup, which convened in late 2011, was charged with helping OPWDD create immediate mechanisms for consistent, streamlined, statewide access to individualized service options prior to full implementation of the People First Waiver. The workgroup and its subcommittees worked through the spring of 2012 to develop the recommendations that are the basis and hallmarks of Individual and Community Supports (ICS). ICS is a person-centered approach to developing plans of support for people; it is not a program or service. ICS is consistent with the direction and structure of the People First Waiver in that it 20
is based on: • • • • •
Person-centered practices; More informed choice of supports and services; Combined use of paid and natural community supports; Statewide consistency in funding and availability of individualized and self-directed service options; and Quality oversight for all individuals receiving services.
ICS will be the way eligible individuals and families seeking OPWDD services access those services. In concert with the goals for the People First Waiver, the ICS philosophy and processes: • • • •
Are driven by the needs of individuals, rather than the services that are currently available; Allow individuals as much authority as they and/or their families and circle of support want regarding the supports and services they receive and who delivers those services; Provide a streamlined process, plan, and budget to simplify access to and support participation in individualized services, and to facilitate portability of funding; and Offer a full array of housing and employment options to encourage individuals seeking services to live and work in their communities of choice.
ICS will be implemented in three phases: • •
Phase 1: Begin with new people entering the OPWDD system (September 2012). Phase 2: Consolidate all individualized services now offered by OPWDD: o Consolidated Supports and Services (CSS) o Portal initiative and portal-like plans o Learning Institute o Individual Supports and Services (ISS), i.e., housing subsidies Phase 3: Expand to include individuals currently being served who want to access services in a less restricted setting.
The OPWDD Front Door is defined as the philosophy, criteria, processes, and procedures that are applied consistently to all individuals seeking supports and services through OPWDD’s service system in any OPWDD region. The Front Door is a person-centered approach that: •
• • • •
Moves the service system from a supply oriented to a demand orientated system, where the services system is driven by the needs of individuals rather than by services currently available within agencies; Supports informed choice and portability where funding follows the person; Facilitates innovative and creative support options; Provides consistency and transparency (i.e., clear criteria and processes); Ensures equity where similarly situated individuals have the same access to supports and services based on consistent criteria and needs assessment tools. The process and procedures for access to, and availability of, ICS services will be consistent and fair across all regions of the state; and Ensures consistent quality oversight for all in individualized services, and demands a continuous quality improvement appraisal to determine how we are doing and where 21
improvement is needed. Planning and design of ICS and the new Front Door began in summer 2012, starting with information sessions for regional office staff; voluntary provider agencies, including the provider associations; Medicaid service coordinators and brokers; and individuals and families. Training sessions on the ICS process, budget template, and policies and guidelines began in August 2012 for the same groups. Training continued through the fall of 2012 and implementation of the ICS plan/budget and the new Front Door process is anticipated for the beginning of 2013. Goal People with developmental disabilities have plans, supports, and services that are personcentered and as self-directed as they choose. Outcomes • • •
Implement a valid assessment process for individuals with developmental disabilities. Establish a cadre of qualified providers that will become DISCOs. Implement ICS policies to support statewide access to individualized services and use of individualized, noncertified service options.
Performance Measures • • •
Number of individuals who participated in the pilot CAS. Availability and choice of qualified DISCOs in New York State. Statewide growth in the utilization of individualized, noncertified service and support options (such as supportive housing and generic community services for volunteerism and other meaningful activities) by individuals already receiving supports and services and those new to the OPWDD service system. Increase in the number of individuals who self-direct their services. Individuals with developmental disabilities who access person-centered services express satisfaction with their supports and services.
Implementing the Mission and Vision Home Developmental Center Closure 2012 marks the 25th anniversary of the closing of the Willowbrook Developmental Center and the beginning of a movement that enabled individuals with developmental disabilities to transition out of institutions and into the community. The state began transitioning people with developmental disabilities in the late 1970s when 20 state institutions housed nearly 30,000 people in New York State. Since then, more than 6,200 community homes have been developed, and 13 institutions have closed their doors. As of October 2012, only 1,052 people continue to receive institutional care. Figure 7 highlights the institutional decline since March 2012.
OPWDD is keeping its commitment to close institutions and create new community opportunities. This was demonstrated with the 2011 closure of the West Seneca Developmental Center and the closure of the Staten Island Multiple Disabilities Unit in June 2012. OPWDD has also announced that the Finger Lakes and Wassaic campus-based residential programs will close by December 2013. As part of OPWDD’s discussions with the Center for Medicare & Medicaid Services on the People First Waiver and future system of supports and services for people with developmental disabilities, the expectation is that institutional capacity will total approximately 150 and be considered a time-limited high intensity service. While some individuals will continue to need intensive supports on an interim basis in campus-based settings, people can, should, and do have the right to live and receive their supports and 23
services in the most integrated community setting possible. OPWDD’s commitment to supporting individuals in the community will assist the transition of an additional 63 people by the end of 2012. As the developmental center census declines, OPWDD will continue to expand the number of appropriate living options for individuals with developmental disabilities through various housing initiatives.
Housing Initiatives Continuum of Housing Options OPWDD is fulfilling its obligations under the ADA and Olmstead decision by developing successful strategies to assist people to live in the least restrictive residential environment possible. To accomplish this goal, OPWDD conceptualized a continuum of housing opportunities to ensure that as institutions decline and a vast statewide system of community services increases, there would be a range of residential options available based on individual needs and abilities, instead of the availability of congregate program models. OPWDD facilitated housing forums to learn more about existing housing arrangements that could meet the needs of individuals with developmental disabilities. By the end of August 2012, almost 1,500 had individuals attended forums on the following topics: • • • • •
Supportive housing Housing options for seniors Rural housing development Family care and shared living Assistive living
New York State Housing and Community Renewal (NYSHCR) Partnership OPWDD recognizes the need for a sustainable infrastructure to expand the continuum of housing opportunities; from individualized housing in the community with few supports to certified housing with 24/7 support. An array of housing options does not currently exist to sufficiently address the needs of individuals who wish to have control or ownership of their own home or apartment. To further meet this need for housing, OPWDD formed a new partnership agreement with NYSHCR which will include specific language in NYSHCR’s funding round starting in 2012. These applications for funding will propose a preference in tenant selection for people with developmental disabilities for up to 10% of a project’s total units. Provider applicants must have firm commitments from OPWDD for operating supports and services funding, and development financing for special needs units. Six providers of supports and services to people with developmental disabilities have submitted applications to NYSHCR for early award funding. OPWDD will develop a sustainable infrastructure to seek ways to possibly support these agencies’ projects. Housing Counseling OPWDD was awarded funds by the U.S. Department of Housing and Urban Development (HUD) in 2012 to strengthen its housing counseling curriculum. OPWDD’s downstate housing office is in the process of developing an education and training curriculum for statewide distribution. The training will help individuals develop the appropriate skills to reside in the community. OPWDD seeks to have a cadre of trained housing coordinators and housing 24
specialists at each of its developmental disabilities regional offices, and its developmental disabilities state operations offices to help people with developmental disabilities understand the pros and cons of living in a less restrictive environment. Supportive Housing Development Program OPWDD was awarded $1.8 million to participate in a new supportive housing development program under the Medicaid Redesign Team’s rental subsidies/services programs. OPWDD will utilize a portion of available funds to assist people to live in apartments with ISS rent subsidies and community habilitation, CSS residential settings, and assist some individuals to move from a 24/7 voluntary-operated individualized residential alternative (VOIRA) to settings with less than 24/7 staffing. OPWDD will match the $1.8 million which, when combined, will provide opportunities to 180 people with intellectual and developmental disabilities to move into less restrictive residential settings. A request for services (RFS) has been developed, which is designed to spread this initiative throughout New York State. Senior Housing Opportunities To create more housing and other options to support the growing cohort of people with developmental disabilities who are aging, OPWDD is researching ways to assist individuals who want to retire from services. OPWDD has engaged the Center for Excellence in Aging at the University at Albany, State University of New York; the State Office for the Aging; and the Department of Health, to learn about residential opportunities that exist and those that may be created for people with developmental disabilities. In addition to these new housing initiatives, OPWDD continues to implement the following programs to make home ownership and integrated housing a viable option for New Yorkers: • • • • •
Home of your Own program; Foreclosure prevention services; Assets for Independence/Individual Development Account/Match Savings program; Home Owner Transit Use Incentive program; and U.S. Department of Agriculture Rural Development Single-Family Housing.
More information about these specific programs is available on the OPWDD website: www.opwdd.ny.gov/opwdd_community_connections/housing_initiative. Goal People with developmental disabilities are living in the home of their choice. Outcomes • • •
Individuals live in the least restrictive residential setting that is appropriate to their needs and abilities. Individuals will have a greater continuum of housing supports available in the community. OPWDD institutional capacity will drop to approximately 150 (over the next four state fiscal years with time-limited stays). 25
Performance Measures • • •
Increase in the percentage of individuals with developmental disabilities living in the most integrated setting. Increase in the number of supportive housing opportunities available in New York State. Decrease in the number of people residing in institutions.
Measurable increase with satisfaction and choice of living arrangements.
Health and Safety Health and Safety Reforms Ensuring the health and safety of individuals with developmental disabilities is one of the highest priorities in all initiatives, which included progress in areas ranging from fire safety to incident reporting and investigations. OPWDD’s goal is to provide supports that foster good health and confidence based on a secure, trustworthy and accountable service system. During the past year, OPWDD implemented the following improvements to enhance state and voluntary provider performance: •
• • •
• • •
Redesigned the Early Alert process, an internal review for agencies that did not meet minimum service delivery standards. OPWDD posts a list of agencies placed on Early Alert on our website with the criteria and reason for early alert status. Centralized the oversight of serious incidents and allegations of abuse. All provider agencies are required to report serious incidents and allegations of abuse into a statewide electronic database. Revised review protocols so that specific data could be obtained about the quality of services and supports being delivered by OPWDD’s provider agencies. Shared the results of Medicaid service coordination reviews with all stakeholders on our website to further develop a provider performance report card. Based on a memorandum of understanding between OPWDD and the Office for Fire Prevention and Control (OFPC), OFPC recently took over the review of Life Safety Code and fire safety requirements at certain OPWDD certified residential programs. Surveyed thousands of state- and nonprofit provider-operated homes and identified priorities for fire safety upgrades. Developed a centralized mortality review system. Provider agencies are required to report all deaths, with pertinent treatment information, into a statewide electronic database. Created a revised local mortality review process that will be piloted in two areas of New York State.
In addition to these accomplishments, OPWDD is working on the following long-range goals for the next few years: • • • • • • •
Revising all review protocols to focus on the quality of individual supports and services, as well as individual health and safety. Developing reports and post information about agencies’ performance in protecting individuals from serious incidents and abuse. Implementing centralized mortality reviews to improve health care and to eliminate preventable deaths. Publishing an annual mortality report, including actions taken to improve services based on any identified trends. Centralizing all certification, authorization, and review activities under the Division of Quality Improvement (DQI) to ensure consistent standards and review procedures. Implementing actions to grow and incentivize the Compass program to recognize and reward agencies that provide the highest quality supports and services. Reviewing current regulations in order to recommend changes that need to be made to better support OPWDD’s values. 27
Developing review procedures for care coordination. Re-energizing the regional advisory committees made up of self-advocates, advocates, and provider agencies to gain input from all stakeholders regarding quality initiatives.
OPWDD has an ambitious agenda to implement over the next few years and will need the support and assistance of all stakeholders. Quality improvement is not a stationary target; there will always be opportunities to improve health and safety outcomes for individuals with developmental disabilities and their family members. Systemic, Therapeutic, Assessment, Respite, and Treatment Services OPWDD is redesigning and strengthening its system for the provision of community-based crisis prevention and intervention services to individuals with developmental disabilities and cooccurring behavioral health needs. Historically, crisis response services varied across the state and were influenced by the changing profiles of the individuals served, geographic differences, fiscal constraints, and resource shortages in the public and private sectors. The new system, based on an evidence-based program called Systemic, Therapeutic, Assessment, Respite and Treatment (START) services, will be designed to address the developmental, behavioral, and mental health needs of individuals within a comprehensive service delivery system. START will include a system for data collection and assessment of program outcomes, consultation, and clinical monitoring teams. The goals of START services are to create an infrastructure that offers crisis response and prevention services when and where they are needed, and create cross-systems linkages and care coordination between OPWDD and other state and voluntary provider agencies. Successful implementation of START services will reduce the likelihood that individuals with complex service needs will find themselves without adequate treatment options when they need them most. During the summer of 2012, OPWDD began to work with leaders at the Center for START Services, located at the University of New Hampshire’s (UNH’s) Institute on Disability, to implement START services. Over the next two years OPWDD will: • • • • •
Assess available services, service gaps, and linkages/affiliations in the regions; Develop a strategic plan to implement START; Receive technical assistance and consultation from UNH to create educational trainings, collect data, and assemble clinical teams; Pilot START services in Region 1 and Region 3; and Develop the START Information Reporting System, a web-based system to collect START services data.
Implementation of a START services program typically takes four years. The present proposal to develop and implement START services runs through June 30, 2014. OPWDD intends for START services to be an integral part of the agency’s mission to help individuals with developmental disabilities live richer lives. OPWDD is committed to seeing the START services initiative to the point of full implementation, and affirming the delivery of START services as a key component in the OPWDD system. Goal People with developmental disabilities experience good health and are safe in their home and community. 28
Allegations of abuse and neglect are always reported and thoroughly investigated by OPWDD and voluntary agencies in a timely manner.
Performance Measures • •
Decrease the percent of investigations closed as inconclusive by at least 15%. Decrease the percentage of investigations taking more than 30 days.
Relationships Positive Relationships Offer More Opportunities to Everyone Positive Relationships Offer More Opportunities to Everyone (PROMOTE) is the OPWDDapproved staff training curriculum designed to support individuals with developmental disabilities, and to assist staff in safely and effectively addressing potential behavioral challenges. This new curriculum replaces the prior staff training program known as Strategies for Crisis Intervention and Prevention-Revised, or SCIP-R. Effective staff training is vital to helping the people we support to lead richer lives and is critical to achieving the agency mission and vision. PROMOTE is intended to reduce the likelihood of challenging behaviors by fostering positive relationships and environments. OPWDD is strongly committed to providing staff with the skills necessary to address behavioral events through the use of positive behavior supports. In PROMOTE, these skills are called primary tools. However, when behavioral events pose an immediate health and safety risk to self or others, it may be necessary to use physical interventions, known as secondary tools, in order to interrupt truly dangerous situations. The PROMOTE program has been designed to train staff to competently respond to behavioral events, including those in which secondary tools may be necessary. Staff are taught that secondary tools are only to be used when the presenting behavior is considered to be a health and safety issue and when other less restrictive interventions are ineffective. Workforce Initiatives Core Competencies In 2011, OPWDD formed a direct support professional core competencies workgroup as part of the New York State Talent Development Consortium. The core competencies for direct support professionals (DSP) encompass all aspects of direct support. They are framed by seven goal areas. The consortium has finalized the DSP core competencies, recommending that they serve as the skill standards for evaluation of direct support professionals throughout the entire developmental disabilities system.
NYS DSP Core Competency Goals Putting People First Building and Maintaining Positive Relationships Demonstrating Professionalism Supporting Good Health Supporting Safety Having a Home Being Active and Productive in Society
Implementation is now under way in the eight nonprofit provider agencies that participate in the workgroup, and in several state offices, and will be expanding to six additional nonprofit agencies represented on the consortium’s steering committee. All providers will begin using the competencies in April 2013 with the goal of full implementation by May 2014. Providers will be required to ensure that their DSP standards are consistent with the New York State core competencies. Resources, including a website containing various tools, learning resources, and strategies, regional support, and information meetings, will be made available for all providers in January 2013. The next project for the Talent Development Consortium will be developing core competencies and providing recommended training tools for direct support professional supervisors. This effort will commence by the end of 2012. Code of Ethics
Key Elements of the NADSP Code of Ethics
In July 2012, OPWDD announced the agency’s adoption of the National Alliance for Direct Support Professionals (NADSP) Code of Ethics, based on the recommendation of the Talent Development Consortium. Development of an implementation plan for the code began in July 2012 with an OPWDD initiative in partnership with NADSP and the College of Direct Support. Six regional DSP dialogues, or workshops, were held to engage DSPs from both the state and nonprofit providers of service.
Person-Centered Supports Promoting Physical and Emotional Well-Being Integrity and Responsibility Confidentiality Justice, Fairness, Equity Respect Relationships Self-Determination Advocacy
In each of the daylong dialogues, groups of approximately 30 DSPs took part in an interactive presentation of the national code of ethics and also serve as focus groups to provide information on key issues facing the profession. That information is now serving as the guiding framework for a system-wide implementation strategy, now in development, for the code of ethics for the more than 90,000 DSPs statewide. Goal People with developmental disabilities experience positive relationships in their lives. Outcomes • •
People with developmental disabilities have meaningful relationships with friends, family, and others of their choice. The OPWDD and voluntary agency workforces are trained to provide positive behavioral supports to individuals with developmental disabilities.
Performance Measures • •
Growth in the number of individuals who experience quality relationships and access community activities. Increase in the number of OPWDD staff who receive PROMOTE training.
Reduce the number of challenging behaviors by fostering positive relationships.
Employment and Meaningful Activities Employment First Initiatives OPWDD continues its efforts to greatly expand the number of people with developmental disabilities who are employed and earning at least minimum wage. Individuals with disabilities must have opportunities to work in the community with people who do not have disabilities, and earn wages that are at or above minimum wage. As of July 2012, participation in supported employment programs grew to over 9,800 people, and OPWDD’s goal is to achieve continued growth through various initiatives. OPWDD is working on multiple fronts to foster employment opportunities for individuals with developmental disabilities. This includes the following: Developing job readiness skills for people who want to work; expanding opportunities for individuals to engage in volunteerism and other meaningful activities; building provider capacity to do quality job development and job coaching; strengthening partnerships with other state agencies; and building relationships with the business community. OPWDD is seeking to move away from day services silos to meaningful community activities. This will be accomplished by eliminating the silos within existing employment programs and blending funding streams in ways that incentivize the delivery of employment supports. The People First Waiver will not only increase opportunities for individuals to live in the community, but also expand opportunities to engage in meaningful community activities. The ultimate aim is to help individuals achieve their maximum level of independence by helping them develop the skills necessary to interact with and be actively engaged in their community. This is consistent with the goals of Olmstead: to help individuals pursue employment and meaningful day activities in the most integrated setting. OPWDD is particularly focused on youth graduating from high school and the system changes that are needed to make employment the first and best option. In addition, individuals who participate in day habilitation, sheltered workshops, or pre-vocational services should have opportunities, if they so desire, to work in integrated community settings. Many of these individuals will be able to work part-time with other wrap around supports that provide meaningful experiences in the community. As the service delivery system transitions to the People First Waiver, OPWDD will support the employment goals of individuals who receive services. In addition, the agency is strengthening partnerships with the Department of Labor, the State Education Department, and OMH to better leverage resources and tools toward better employment outcomes for people with developmental disabilities. Community Service Initiative As part of the community service initiative, OPWDD will partner with its network of over 700 nonprofit provider agencies, self-advocacy groups, and parent groups across the state to increase opportunities for individuals with developmental disabilities to participate in national service programs.
OPWDD will leverage existing networks to conduct outreach and raise awareness of community service opportunities for individuals with disabilities, build capacity among voluntary agencies to engage those individuals in volunteer programs, and provide training to community-based organizations on ways to more effectively recruit, train, and place individuals with developmental disabilities in national or community service positions. The community service project will help OPWDD utilize volunteering to educate businesses about the contributions and differences that people with developmental disabilities can make in their communities. Volunteerism can create a pathway for people with developmental disabilities to become a greater part of the New York State workforce. By connecting community service and volunteering to work and career exploration, individuals with developmental disabilities will develop the job skills and work experience needed to transition to integrated employment. Monthly Community Habilitation OPWDD continues to work on the development of building blocks that provide greater choice and flexibility in service provision, by broadening the menu of community integrated service options for people with developmental disabilities. One of these important building blocks is Phase 2 of community habilitation, which was implemented in November 2012. Phase 2 of community habilitation will expand this service option to individuals who reside in certified settings and have chosen to receive day habilitation and residential habilitation from the same provider. Phase 1 of community habilitation, implemented on November 1, 2010, was designed to enable more flexible service provision for individuals with developmental disabilities residing in non-certified settings. Similar to Phase 1 of community habilitation, Phase 2 enables people who live in certified settings to have greater flexibility and choice in how they spend their day and where they receive their habilitative supports. Phase 2 of community habilitation enables providers to work with individuals to design more tailored and creative approaches to habilitation services by separating the financing of supports from the site of service delivery—an important step to break down service delivery silos as OPWDD’s system moves into the future. OPWDD held two video conference training sessions across the state in September 2012 to orient providers to Phase 2 of community habilitation. The training included programmatic topics, service documentation topics, and fiscal and billing topics. Further guidance on community habilitation is available on OPWDD’s website: www.opwdd.ny.gov/regulations_guidance/opwdd_regulations/hourly_community_habilitation. Faith-Based Initiative The first goal of the Faith-based Initiative is to assist individuals with developmental disabilities to participate as valued members in their faith community. Through consistent interaction with members of their faith community, individuals with developmental disabilities will build friendships and natural supports that provide additional opportunities to be involved in their community and practice their faith beliefs. OPWDD’s second goal is to assist individuals with developmental disabilities to extend their choices for community involvement beyond houses of worship to other areas of community integration including living in a home or an apartment of their own, access to employment,
volunteerism, as well as other activities that make up the fabric community life. This can be done by utilizing the friendships developed within the faith community to create networking opportunities in these other areas (i.e., home, work, recreation). To meet these goals for faith-based community inclusion, OPWDD will: •
Provide statewide training (via webinars and video conferences) on spiritual indicators for Medicaid service coordinators and others charged with identifying the choices and interests of individuals with developmental disabilities; Address policies that hinder community involvement; Provide online interactive training sessions for state and voluntary agency staff to meet core competencies on awareness of individuals with developmental disabilities’ spirituality; Examine how social network opportunities (e.g., Facebook, Google+, Twitter) may impact the ability of individuals to develop meaningful relationships within their community; and Train faith community leaders to assist state and voluntary agencies in breaking through some of the barriers to community involvement (i.e., transportation, opportunities).
Faith Community Development Grant In October 2012, OPWDD was awarded an 18-month community inclusion grant from the New York State Developmental Disabilities Planning Council (DDPC) to increase individuals with developmental disabilities’ access and inclusion in the congregation of their faith and choice. The Faith Community Development Grant will improve opportunities for person-centered and meaningful community participation and engagement in at least five areas of community life. Some of the goals of this grant align with the overall goals of the Faith-based Initiative program. As a grantee, OPWDD must meet specific performance metrics for the next 18 months, including: • • •
Engaging two nonprofit provider agencies in each of the five regional offices to participate in the grant. Documenting 100 people with developmental disabilities who have a goal of greater involvement in a congregation or other area of spiritual development. Documenting at least 50 people with developmental disabilities who as a result of project activities have greater involvement in the congregation or spiritual direction of their choice. Researching and developing a report on nationwide congregational inclusion strategies and techniques to promote best practices for individuals with developmental disabilities to live in their communities. Documenting strategies and best practices that lead to the congregational inclusion of project participants, especially those that overcome funding and policy barriers.
People with disabilities are able to work in jobs that are equal to or greater than minimum wage and/or participate in their communities through meaningful activities.
Outcomes • • •
Employment will be the first and preferred option for all people with developmental disabilities. Individuals will receive employment services and have meaningful activities in the most integrated setting possible. Individuals will develop relationships and participate in their community through volunteer opportunities and faith-based practices of their choice.
Performance Measures • • •
Increase in the number of individuals who are employed in integrated jobs (including those that pay minimum wage or higher). Increase in the number of people who are involved in their faith community or spiritual practice of choice. Growth in the percent of individuals who volunteer in the community.
Conclusion The Statewide Comprehensive Plan demonstrates OPWDD’s efforts to undertake and implement system change and create well developed, person-centered services to support individuals with developmental disabilities and their families. Our vehicle for system transformation is the People First Waiver, a 1915 b/c waiver, which combines long-term care services, behavioral health, and acute care services to holistically meet the total needs of people with developmental disabilities. OPWDD will submit waiver applications to CMS and anticipates approval by October 2013. Over the next year, OPWDD will continue to work with all stakeholders to reform the developmental disabilities system in New York State. While many things will change, OPWDD will continue to focus on its mission and vision to provide individuals with disabilities with a choice of home, employment and meaningful activities, good health, and meaningful relationships.
Appendix A Summary of 2013 County Plans Introduction The 2013 local service plan represents the fourth year of interagency collaboration among OASAS, OMH, and OPWDD. Article 41.16 of the New York State Mental Hygiene Law (MHL) requires each of the 62 counties to develop a local services plan to address the service needs of its citizens. To foster integrated collaboration, counties utilize a planning process that involves the local agency offices, individuals with disabilities, advocates, family members, service providers, and state agency representatives. Interagency collaboration improves health outcomes for individuals with co-occurring disorders who receive services from multiple state agencies. A statewide, web-based county planning system (CPS) allows counties to identify priorities among all three disability populations and identify issues that cross traditional lines of each service system. CPS is an efficient and cost-saving application that benefits stakeholders who participate in the planning process, and provides a mechanism to analyze data and trends applicable to individuals receiving services from OASAS, OMH, and OPWDD. Priority Outcomes and Strategies Each county plan identifies priority outcomes and strategies to be achieved across all three mental hygiene agencies. A priority outcome is a broad statement of a realistic and desired goal that the county hopes to achieve over a specific period of time. This outcome statement reflects the mission, vision, and values of the individual agencies and also articulates short-term and multi-year actions to be taken. Most priority outcomes include at least one strategy to accomplish activities defined in that specific priority. A strategy is a measurable statement/objective about what needs to occur to achieve the stated outcome. Outcomes for 2013 County data from the past four years reveal a significant decrease in the number of priority outcomes and a substantial increase of collaboration among the mental hygiene agencies. This year, county plans included a total of 427 priority outcomes, a 32.9% decrease from 2011. The reduction in priority outcomes was attributed to the consolidation of priorities that are common to multiple disability areas. Also contributing were limited resources and impending health system changes accompanying Medicaid redesign. Multiple agency collaboration translated to 101 separate strategies applicable to OPWDD and 193 strategies that address all three disability agencies. Table 1 compares priority outcomes in 2010 and 2013 for all three agencies. There were 427 priority outcomes reported in 2013 versus 666 identified in 2010. This change reveals a 37% decrease in reported priority outcomes. Also, there were 167 priorities for OPWDD in 2010 and 51 priority outcomes in 2013, a 63% decrease. In 2013, OASAS and OPWDD shared only one priority outcome, whereas OMH and OPWDD shared 27 priority outcomes. Together, the three agencies shared 194 priority outcomes.
Table 1. County Priority Outcomes by Disability Area (2010 versus 2013) Disability Combination
A notable finding is that the total number of priority outcomes reported by the combined agencies increased by 12.1% over the past two years, whereas all other agency specific changes resulted in decreases. This trend suggests that individuals have multiple needs that require services across the three systems. The information in Figure 1 represents themes identified from an analysis of the 51 (OPWDD only) priority outcomes and associated strategies. Of these priority outcomes, housing, employment, and respite represent the highest priority needs in 2013. The narrative in the county plans suggest that counties focused more collaboration on outcomes affecting persons with co-occurring disorders who may need services from multiple systems, or persons within each system that may need similar services (e.g., housing, employment, respite, transportation, and family support). System collaboration, access to services, and health care reform are mentioned within other themes in the narrative. Brief highlights of the top six themes are discussed below. Figure 1. OPWDD Agency Specific Priority Outcome Themes
Health Care Reforms Identification/Access to Services System Collboration Transition for students Family Support Transportation Respite Employment Housing 0
Housing: Safe, accessible and affordable housing is the highest priority need that affects counties in rural and urban areas. For rural settings there is a lack of adequate housing options available. In urban settings the cost of housing prevents individuals from affording fair market rent or home ownership. Several rural counties identified the need for permanent and temporary emergency housing for individuals; however, funding for housing development is an obstacle due to limited resources. Most rural counties stress the promotion of noncertified individualized housing options through programs such as ISS and CSS to accommodate part of this need. Counties suggest that more outreach needs to be done to help individuals and families understand the benefits of integrated housing options. Employment: Counties discussed how low employment rates of individuals with disabilities are tied to the economy, especially in upstate New York. One of the initiatives that will help employment providers is the implementation of the New York Employment and Services System, which will help individuals with disabilities find jobs and help professionals track employment data and post job opportunities. Counties also cited the need to expand supported employment services, especially for transition age youth. Respite: Family, crisis/emergency, and temporary respite is cited as a critical resource to help people live safely, remain in their homes, and provide families with relief from care giving. Similar to housing, rural counties do not have an adequate supply of respite opportunities. Service providers reported the need to coordinate respite in their communities to best utilize this limited resource. Steps include: 1. 2. 3. 4.
Developing and implementing a needs assessment for respite services. Developing adequate resources, based on needs assessment for respite. Creating a mechanism to assure effective coordination of respite services. Promoting awareness of the availability of respite services.
Transportation: Transportation alternatives are limited in rural counties. Medicaid transportation is available for medical appointments, but for individuals not on Medicaid or those needing special arrangements, lack of this type of transportation often hinders their ability to remain in the community. Counties cite that individuals engaged in treatment and able to access services in their county have increased sense of well-being and satisfaction. One local county provider utilizes software to communicate transportation needs and availability to all providers county-wide. Family Support: As the Medicaid system transitions to managed care, individuals and family members will need training to fully understand upcoming changes and the effects on access to services and supports. Training should include information about natural support mechanisms, new approaches to assessment, and the plan of care. Successful systems transformation depends on collaboration and sharing of information among the state, counties, providers, people with disabilities, and family members. Transition for Students: Counties express that many individuals with developmental disabilities lose their naturally occurring social networks following their transition from the educational system into the adult services system. Individuals require support to develop relationships and participate in their communities. Also critical to transition planning is the need to link the person’s individual education plan, beginning at age 14, to the person-centered planning process to achieve greater independence and connection to community-based services and supports. 40