2010 Ted Strickland, Governor Amy Rohling McGee, Interim Executive Director Ohio Executive Medicaid ODJFS BALANCING AND BEYOND: A VISION FOR COMMUNITY SERVICES AND SUPPORTS FOR INDIVIDUALS WITH DISABILITIES Compiled by the Executive Medicaid Management Administration (EMMA) with content provided by Ohio’s Single State Medicaid Agency, The Ohio Department of Aging, The Ohio Department of Developmental Disabilities, The Ohio Department of Mental Health, The Ohio Department of Alcohol and Drug Addiction Services, The Ohio Department of Health, The Ohio Rehabilitation Services Commission, Ohio Department of Education, and Ohio Department of Insurance. TABLE OF CONTENTS EXECUTIVE SUMMARY ........................................................................................................... 5 I. INTRODUCTION ........................................................................................................... 8 II. WHO RELIES ON LONG-TERM SERVICES AND SUPPORTS? ........................................... 10 III. OVERVIEW OF PROGRESS SINCE 2007 ........................................................................ 11 1. INCREASE COMMUNITY CAPACITY ..................................................................................... 12 2. PRIORITIZING RESOURCES ............................................................................................... 12 3. ASSURING QUALITY AND ACCOUNTABILITY ......................................................................... 13 IV. SNAPSHOT OF OHIO’S FISCAL AND ORGANIZATIONAL STRUCTURE ............................. 14 OHIO’S SINGLE STATE MEDICAID AGENCY .................................................................................... 14 THE OHIO DEPARTMENT OF AGING ............................................................................................. 14 THE OHIO DEPARTMENT OF DEVELOPMENTAL DISABILITIES ............................................................. 14 THE OHIO DEPARTMENT OF MENTAL HEALTH ............................................................................... 14 THE OHIO DEPARTMENT OF ALCOHOL AND DRUG ADDICTION SERVICES (ODADAS) ............................ 15 THE OHIO DEPARTMENT OF HEALTH ........................................................................................... 15 THE OHIO REHABILITATION SERVICES COMMISSION ....................................................................... 15 OHIO DEPARTMENT OF EDUCATION ............................................................................................ 15 OHIO DEPARTMENT OF INSURANCE ............................................................................................. 16 V. STRATEGIES TAKEN TO MOVE TOWARDS REBALANCING OHIO’S LONG-TERM SERVICES AND SUPPORTS SYSTEM (2007-2009) ......................................................................... 17 A. NURSING FACILITY POLICY CHANGES ................................................................................. 17 B. IMPLEMENTED HOME CHOICE: OHIO’S MONEY FOLLOWS THE PERSON TRANSITION PROGRAM .. 18 C. OHIO CONTINUES TO ADD MORE SELF-DIRECTED SERVICES WITHIN MEDICAID WAIVERS .............. 20 D. UNIFIED LONG-TERM CARE BUDGET WORKGROUP .............................................................. 20 E. RESTRUCTURED OHIO’S DEVELOPMENTAL CENTER AND HOME AND COMMUNITY-BASED SETTING CAPACITY..................................................................................................................... 20 F. INCREASED BUDGET FOR DEVELOPMENTAL DISABILITIES WAIVERS. ........................................... 21 G. REGIONAL RESOURCE CENTERS ........................................................................................ 21 H. CREATED THE MEDICAID IN SCHOOL PROGRAM ................................................................... 21 I. IMPLEMENTED THE OHIO SECONDARY TRANSITION IMPROVEMENT GRANT (OSTIG) ................. 22 J. IMPLEMENTED OHIO’S MEDICAID BUY-IN FOR WORKERS WITH DISABILITIES (MBIWD) PROGRAM................................................................................................................................. 23 K. WORKING TOWARDS EXPEDITED SSI AND MEDICAID ............................................................ 23 L. IMPLEMENTED OHIO’S INTENSIVE HOME AND COMMUNITY BASED TREATMENT (IHBT) GRANTS SFY08-09 ................................................................................................................... 24 M. IMPLEMENTED MEDICAID ACCESS IMPROVEMENT FOR INDIVIDUALS LEAVING CORRECTIONAL INSTITUTIONS ............................................................................................................... 24 VI. BALANCING INITIATIVES IN PROGRESS (2010 AND BEYOND) ...................................... 26 A. CREATION OF THE STATE PROFILE TOOL ............................................................................. 26 B. CREATION OF THE HOME CHOICE ADVISORY COUNCIL ........................................................ 28 C. CREATING OHIO’S HEALTH AND HUMAN SERVICE LATTICE .................................................... 28 D. CONTINUE DEVELOPING A UNIFIED LONG-TERM CARE SYSTEM .............................................. 29 E. QUALITY MANAGEMENT SYSTEM ..................................................................................... 30 F. IMPROVED QUALIFICATIONS FOR DIRECT SUPPORT STAFF ....................................................... 31 G. FUTURES WAIVER ......................................................................................................... 32 H. IMPROVING SUPPORT AND SERVICES FOR INDIVIDUALS WITH CHALLENGING BEHAVIORS ............... 32 I. ADULT DAY SERVICES AND VOCATIONAL HABILITATION PROVIDERS ........................................ 33 J. PROVIDED EMPLOYMENT ASSISTANCE FOR OHIOANS WITH DISABILITIES .................................... 33 K. EMPLOYMENT INITIATIVES ............................................................................................... 33 L. DEVELOPING PERMANENT AND SUPPORTIVE HOUSING ......................................................... 35 VII. PROGRAMS AND SERVICES FOR INDIVIDUALS WITH DISABILITIES ACROSS THE LIFESPAN ................................................................................................................................. 38 A. ODADAS FETAL ALCOHOL SPECTRUM DISORDER INITIATIVE ................................................. 38 B. EARLY INTERVENTION ..................................................................................................... 38 C. HELP ME GROW ........................................................................................................... 39 D. BUREAU FOR CHILDREN WITH MEDICAL HANDICAPS (BCMH) ............................................... 41 E. OHIO’S MEDICAID PROGRAMS AND SERVICES ..................................................................... 42 F. OHIO ACCESS SUCCESS PROGRAM .................................................................................... 45 G. SERVICES PROVIDED UNDER THE OLDER AMERICANS ACT ...................................................... 45 H. OHIO’S INDEPENDENT LIVING OLDER BLIND PROGRAM ........................................................ 46 I. PERSONAL CARE ASSISTANCE PROGRAM ............................................................................ 47 J. OHIO’S ANTI-STIGMA CAMPAIGN .................................................................................... 47 K. OHIO’S STIGMA BUSTER ................................................................................................. 48 L. OHIO’S ASSERTIVE COMMUNITY TREATMENT (ACT) ............................................................ 48 M. OHIO’S CONSUMER OPERATED SERVICES/PEER SUPPORT ORGANIZATION AND CONSUMER BENEFITS PACKAGE INITIATIVE ...................................................................................................... 49 N. ODMH HOUSING ASSISTANCE PROGRAM ......................................................................... 49 O. ODMH COMMUNITY CAPITAL FOR HOUSING ..................................................................... 50 P. ODMH MATCH FUNDING FOR OHIO DEPARTMENT OF DEVELOPMENT (ODOD) HOMELESS ASSISTANCE GRANT ....................................................................................................... 50 Q. MATCH FUNDING FOR U.S. DEPARTMENT OF HOUSING AND URBAN (HUD) CONTINUUM OF CARE (COC) GRANT .............................................................................................................. 50 R. OHIO’S MENTAL HEALTH HOUSING LEADERSHIP INSTITUTE (MHHLI OR THE INSTITUTE) ............ 50 S. OHIO’S INDEPENDENT LIVING CENTERS ............................................................................. 51 T. OHIO’S PROJECTS FOR ASSISTANCE IN TRANSITION FROM HOMELESSNESS (PATH) .................... 51 U. EXPANDING COMMUNITY LIVING OPTIONS .......................................................................... 52 1. V. ................................ OHIO’S SUPPORTED EMPLOYMENT COORDINATING CENTER OF EXCELLENCE ............................................................................................................................... 52 W. BUSINESS ENTERPRISE PROGRAM ..................................................................................... 53 X. OHIO’S LONG TERM CARE INSURANCE PARTNERSHIP ........................................................... 54 VIII. FEDERAL HEALTH CARE REFORM AND LONG-TERM SERVICES AND SUPPORTS ............ 55 IX. CHALLENGES .............................................................................................................. 57 EXECUTIVE SUMMARY On June 22, 2009, President Barack Obama celebrated the 10th anniversary of the Supreme Court decision in the case of Olmstead v. L.C, and launched “The Year of Community Living,” a new effort to assist Americans with disabilities. In the Olmstead v. L.C. decision, the Court stated that unnecessary segregation of persons with disabilities is discrimination under the Americans with Disabilities Act (ADA), and that a state must provide community-based treatment to qualified individuals under certain circumstances. Each state must show their compliance to this decision by either, developing a plan or developing strategies to assure that individuals with disabilities are afforded options to live within the community. To address the Olmstead v. L.C. decision the following principles were adopted in 2000 as a part of Ohio.s initial Olmstead Plan: . Increase Community Capacity . Prioritize Resources . Assure Quality and Accountability In response to the 10th anniversary of Olmstead, the cabinet agencies that comprise the Executive Medicaid Management Administration (EMMA), as well as the administrator of the Rehabilitation Services Commission (RSC), met to discuss Ohio.s Olmstead Plan, last updated in 2006 and known as the Ohio Access Report. There was agreement that while a number of Olmstead-related activities had been pursued in the three years since the last update, these were not described and compiled in one document, such as: . Allow individuals to continue working without losing their eligibility to receive Medicaid benefits (Medicaid Buy-In Program) . Enable Ohioans to move from an institutional setting to a community-based setting and invest in long-term services and supports system change (Money Follows the Person/ Ohio.s HOME Choice Program) . Develop a plan for a unified long-term care budget to help Ohio balance spending in such a way as to expand the choices available for long-term care, eliminate barriers for people moving from institutions to home and community-based settings, and assure a wide variety of options in appropriate care for different levels of care. (Unified Long-Term Care Budget) This document, Balancing and Beyond: A Vision for Community Services and Supports for Individuals with Disabilities, describes existing and future initiatives to offer people with disabilities greater choice in living arrangements and services that support independent living. Balancing and Beyond also describes services intended to intervene early to prevent the progress of potentially disabling conditions. The EMMA directors and RSC Administrator charged EMMA staff with creating a plan that not only addresses the state.s approach to Olmstead, but that also articulates a more comprehensive plan for serving people with disabilities. To assist EMMA staff develop this comprehensive document detailing existing and future initiatives, services, and strategies geared toward people with disabilities, EMMA directors and the administrator of RSC designated a senior level staff person to provided policies and programs that they would like to have highlighted. The plan structure is as follows: Section I: Introduction The Introduction informs readers of how the Administration decided to organize this plan to not only adhere to the Olmstead Decision but also inform the public of programs available to consumers across the life- span, from preventative care to new initiatives for supportive housing for individuals with disabilities. Section II: Who relies on Long-Term Services and Supports? This section provides readers with descriptive information and demographic data regarding Ohioans with disabilities. Section III: Overview of Progress Since 2007 This section provides readers with a basic update of policy initiatives that have been implemented since 2007 that increase community capacity, prioritize resources and assure quality and accountability such as: implementation of the Money Follows the Person Grant, a number of the Unified Long-term Care Budget Workgroup recommendations and the Futures Workgroup recommendations, as well as the Medicaid Buy- In Program for Worker.s with Disabilities, to name a few. Section IV: Snapshot of Ohio’s Fiscal and Organizational Structure Because Ohio.s long-term care system spans several agencies, this section helps the reader understand how Ohio.s system is structured and describes the programs that each agency administers for individuals with disabilities. Sections V-VI Ohio continues to develop and pursue strategies to improve access to quality community living for individuals who need long-term services and supports. Sections V-VI articulates the strategies Ohio has taken to rebalance Ohio.s long-term services and supports system and what initiatives are in progress to attain Ohio.s vision for long-term services and supports for individuals with disabilities. Ohio.s vision is to develop a system for long-term services and supports that is flexible, accessible, and affordable so that Ohioans with disabilities may choose from a wide array of quality services based on their preferences and changing circumstances. The system should also be responsive to culture and values, fiscally transparent, and cost-effective. By striving to attain this vision, Ohio will lay a foundation to achieve the objectives of the Olmstead Decision and a system that values the contributions and abilities of people living with physical and mental challenges. Section VII: Programs and Services for Individuals with Disabilities across the Lifespan As mentioned above, the EMMA directors and the administrator of RSC wanted a plan addressing not only the state.s approach to Olmstead, but also articulating a more comprehensive plan for serving people with disabilities. This section highlights programs and services for individuals with disabilities beyond balancing, such as: . Preventive programs such as Help Me Grow; . Medicaid Waiver programs that allowing individuals to stay in the community setting of their choice while they receiving care; . Ohio.s Personal Care Assistance Program; . Employment assistance programs; and . Programs for individuals with behavioral health needs. Section VIII: Federal Health Care Reform and Long-Term Services and Supports Ohio.s long-term care strategies are obligated to operate in the context of federal policy. Health care reform, if passed, will result in the most comprehensive change in both federal and state health care policy in decades. This section outlines Ohio.s predicted impact of federal health care reform legislation. Section IX: Challenges The Operating Budget for State Fiscal Year.s 2010-2011 was developed during one of the most devastating economic downturns in recent history. Ohio leaders introduced strategic funding mechanisms that were introduced to balance the budget necessary because Ohio is required to operate on a balanced budget pursuant to the Ohio Constitution. A substantial temporary increase in federal Medicaid assistance (FMAP) enabled the Medicaid agencies to avoid cuts in benefits or enrollment for this biennium. However, several agencies had to reduce expenditures in other ways. The slow recovery and temporary nature of the increased FMAP means all of the agencies are already in the planning stage for the next biennial budget driven in part by the assumption that the increased FMAP will not continue. This section describes some of the challenges agencies are currently experiencing. I. INTRODUCTION In 2009 the cabinet agencies that comprise the Executive Medicaid Management Administration (EMMA), as well as the administrator of the Rehabilitation Services Commission, met to discuss Ohio.s Olmstead Plan, last updated in 2006 and known as the Ohio Access Report. There was agreement that while a number of Olmstead-related activities had been pursued in the three years since the last update, these were not described and compiled in one document. There was further consensus that a revised plan should reflect a vision for services and supports for individuals with disabilities, in addition to Ohio.s commitment to individuals who are elderly and/or have a disability; while at the same time acknowledging the challenges and difficult decisions this Administration has faced given the state of the economy. In Olmstead v. L.C., a 1999 U.S. Supreme Court decision, the Court stated that unnecessary segregation of persons with disabilities is discrimination under the Americans with Disabilities Act (ADA) and that a state must provide community-based treatment to qualified individuals when: . The state.s treatment professionals determine it is the most appropriate setting; . The person (or authorized representative) does not oppose home and community-based treatment; and . Placement can reasonably be accommodated taking into account the resources available to the state, including consideration of the needs of others. There are two ways a state can show that it is complying with the ADA: . A comprehensive, effective working plan for placing qualified persons with disabilities in less restrictive settings, as well as, demonstrating that waiting lists (if any) move at a reasonable pace; Alternative strategies for placing qualified persons with disabilities in less restrictive settings. Ohio has adhered to this decision by informing the general public of its strategies for placing qualified persons with disabilities in less restrictive settings and by creating alternative strategies for placing qualified persons with disabilities in less restrictive settings. This document, Balancing and Beyond: A Vision for Community Services and Supports for Individuals with Disabilities, will describe existing and future initiatives to offer people with disabilities greater choice in terms of living arrangements and services that support independent living. Balancing and Beyond will also describe services intended to intervene early to prevent the progress of potentially disabling conditions. The EMMA directors and RSC Administrator charged EMMA staff with creating a plan that not only addresses the state.s approach to Olmstead, but that also articulates a more comprehensive plan for serving people with disabilities. Specifically, EMMA was charged with compiling existing and future initiatives, services, strategies and challenges geared toward people with disabilities from relevant cabinet agencies and RSC. The Strickland Administration envisions Ohio.s system of long-term services and supports to be flexible, accessible, and affordable to enable Ohioans with disabilities the ability to choose from a wide array of quality services based on their preferences and changing circumstances, and be responsive to culture and values, fiscally transparent, and cost-effective. If we achieve this vision, we will likely have met the objectives of the Olmstead decision as well as laid a foundation for a system that values the contributions and abilities of people living with physical and mental challenges. II. WHO RELIES ON LONG-TERM SERVICES AND SUPPORTS? Individuals relying on long-term services and supports include people with physical or developmental disabilities regardless of age, those suffering from debilitating chronic conditions or mental illness, and the frail elderly. We all have a personal connection to the people behind these statistics. Many live with a disability or care for someone who does; for example, a child with autism, a sibling with developmental disabilities, a spouse with muscular dystrophy, or a grandparent with Alzheimer.s disease. We often encounter disability without knowing it such as a co-worker recovering from mental illness or a neighbor struggling with an addiction. Approximately two million Ohioans are age 60 or older, and as a group account for more than 17 percent of the state.s population. Beginning in 2006, about 12,000 baby boomers turn 60 each month. One of the many challenges Ohio faces is how best to provide needed long-term care services and supports to this growing population segment who, research has shown, will not only need these services, but will demand they be provided differently than in the traditional models of institutional care. According to the Scripps Gerontology Center at Miami University, the number of Ohioans of all ages who will need long-term services and supports will increase by 14 percent (43,600 consumers) between now and 2020. Prevalence of disability increases with age; currently one in three people over the age of 60 have at least one disability. The 75-plus age group is the fastest growing in the state, and approximately half of them have a long-term disability. According to the Cornell University 2007 Disability Status Report, nearly 353,000 of 694,000 individuals ages 75 and older (50.9% of that age group) report to have one or more disabilities. The Report also stated that in Ohio: . 7.8% of persons ages 5 to 15 reported having one or more disability; . 8.0% of persons ages 6 to 20 reported having one or more disability; . 14.1% of persons ages 21 to 64 reported having one or more disability; and . 28.1% of persons ages 65 to 74 reported having one or more disability. Many discussions have occurred in Ohio in the last few years regarding the need to “balance” the state.s publicly funded long-term care services and supports system. Ohioans would like to see more community- based options that enable elders and people with disabilities the opportunity to live in a setting of their choice. III. OVERVIEW OF PROGRESS SINCE 2007 The following principles were adopted in 2000 as a part of Ohio.s initial Olmstead Plan: . Increase Community Capacity: Publicly financed delivery systems should be responsive to consumer demand for choice of services and supports and the need to develop additional capacity in community-based services. Current delivery systems must be improved to assist families, communities, and state and local governments in meeting their responsibilities. . Prioritize Resources: Reform/expansion of any delivery system must be accomplished by balancing competing priorities within the limited resources of families, community-based organizations, and state and local governments. Government agencies need to develop a process to determine where reform is most needed and can be achieved. Part of this is seeking cost efficiencies and appropriateness of care, especially in institutional settings, thereby making more dollars available to support community-based care. . Assure Quality and Accountability: All publicly financed delivery systems must assure clinical, programmatic and fiscal accountability and compliance at federal, state, local, and provider levels. Responsibility must be clearly defined at each level to ensure significant aspects of program design, including quality assurance, consumer health and safety, and sufficient and appropriate match. The Strickland Administration affirmed these principles and together with the Legislature funded the following initiatives in H.B. 119, Ohio.s operating budget for State Fiscal Years 2008-2009: . Extended the Access to Better Care (ABC) Initiative to reduce out of home placement through improving access for children and families to behavioral health services and supports in their homes, schools and communities; . Implemented the Medicaid Buy-in Program for working individuals with disabilities; . Implemented the Money Follows the Person Program which enables Ohioans to return home and invests in long-term services and supports system change; . Provided sufficient resources to build the capacity of providers of home and community-based care; . Provided state funding of $6.2 million in fiscal year 2008 and $29.0 million in fiscal year 2009 to allow 600 individuals to receive an Individual Options Waiver in fiscal year 2008 and 900 individuals in fiscal year 2009; in compliance with the Martin v. Taft consent order; and . Initiated a plan for a unified long-term care budget that will help the state balance spending in such a way as to expand the choices available for long-term care, eliminate barriers for people moving from institutions to home and community-based settings, and assure a wide variety of options in appropriate care for different levels of care. During the development of State Fiscal Year.s 2010-2011 Operating Budget, also known as H.B.1, the Strickland Administration and the Legislature were faced with the worst economic challenges in recent history. Congress assisted states through this deteriorating economic situation with the passage of the American Recovery and Reinvestment Act (ARRA) of 2009, Ohio was provided a general 6.2 percent increase in the reimbursement rate for the Medicaid Program, known as FMAP. The availability of enhanced FMAP during the fiscal year 2010-2011 impacted the General Revenue Fund (GRF) in two ways. First, Ohio was able to draw additional federal revenue into the GRF for every state GRF dollar spent on Medicaid services (which increased the state.s buying power). Secondly, non-GRF Medicaid funds also drew down enhanced FMAP which enabled Ohio to defray a greater portion of estimated Medicaid expenditures onto non-GRF funds, thereby helping to compress the overall unexpected increased reliance for GRF to support Medicaid. This in turn, assisted Ohio balance the General Revenue Fund. Even through this difficult economic time, Ohio remained committed to the three guiding principles of increasing community capacity, prioritizing resources and assuring quality and accountability and implemented the following strategies: 1. Increase Community Capacity . Lifted the restriction of 1,800 participants to increase the size of the Assisted Living Waiver to serve up to 3,000 participants in SFY 2010 and 4,000 in SFY 2011; . Continued the implementation of the pricing model for Nursing Facility Reimbursement; . Continued implementation of the Medicaid School Program; . Continued funding to the Ohio Access Success Program; . Encouraged partnership between community-based long-term services and supports and housing through the Governor.s Interagency Council on Homelessness and Affordable Housing; . Continued work to revise the “front door” to long-term services and supports; and . Developed Home Care Attendant Service. 2. Prioritizing Resources . Ohio has significantly increased the number of Individual Options and Level One Waivers; . Ohio reduced the total number of State-run Developmental Center (ICF/MR) beds; . Ohio increased the amount of the budget dedicated to waivers for consumers with developmental disabilities; . Ohio implemented Assertive Community Treatment which actively engages persons with severe mental illness to assist them in finding housing and meets other basic life needs including health care; . Ohio Funded the Money Follows the Person Demonstration (HOME Choice) Grant; . Ohio is providing residents of nursing facilities immediate access to PASSPORT, Assisted Living, PACE, and the Residential State Supplement Program through Home First provision in Ohio law; and . Ohio set aside additional dollars from the Capital Budget for distribution to county boards of developmental disabilities for participation in the Capital Housing program. 3. Assuring Quality and Accountability . Enhanced the comprehensive Quality Management System to assure the health and safety of individuals with developmental disabilities, no matter where they receive services; . Continued development of Ohio.s Profile of Long-Term Services and Supports; and . Continued work to develop a consumer council (with paid travel and support services) to enable persons with disabilities to provide guidance to policy and operations. IV. SNAPSHOT OF OHIO’S FISCAL AND ORGANIZATIONAL STRUCTURE Ohio’s Single State Medicaid Agency The Ohio Department of Job and Family Services (ODJFS) is the Single State Medicaid agency, which is the largest funding source for state funded long-term care services and supports. As the Single State Medicaid Agency, ODJFS administers an extensive state plan benefit, the Ohio Home Care Waiver, the Transitions MRDD Waiver, the Transitions Care-Out Waiver (additional information about waiver programs can be found on pg. 42 of this Plan) and the HOME Choice Transition program and through interagency agreements oversees the management of the other Medicaid funded programs delivered by the Departments of Aging, Developmental Disabilities, Health, Mental Health, Alcohol and Drug Addiction Services and Education. ODJFS is also responsible for adult protective services and employment programs. The Ohio Department of Aging The Ohio Department of Aging (ODA) manages three Medicaid waiver programs, including PASSPORT, Choices, and the Assisted Living Waiver. PASSPORT provides care to elders in their own homes. Choices is a subset of PASSPORT which allows Medicaid reimbursement for the self direction of care, including choosing caregivers. The Assisted Living Waiver provides Medicaid funding for care in assisted living settings. The Department of Aging maintains contractual relationships with Area Agencies on Aging to manage various aspects of the PASSPORT and Choices programs. In addition to the three waiver programs, ODA is the state authority for the Program of All-Inclusive Care for the Elderly (PACE) which currently operates in Cincinnati and Cleveland. Through its federal Older Americans Act funding, ODA administers the National Family Caregiver Support Program in Ohio. The Ohio Department of Developmental Disabilities The Ohio Department of Developmental Disabilities (DODD) provides both institutional and community based Medicaid services. The department operates ten developmental centers which provide institutional services and in partnership with county boards of developmental disabilities, the department also manages two Medicaid waivers (Individual Options and Level One) which enable people with developmental disabilities to live in a community instead of an ICF/MR. The Ohio Department of Mental Health The Ohio Department of Mental Health (ODMH), in partnership with county Alcohol, Drug Addiction and Mental Health boards, provides community mental health services to approximately 200,000 Medicaid consumers. These services include pharmacological management, community psychiatric supportive treatment, partial hospitalization counseling, psychotherapy, diagnostic assessments and crisis intervention. The Ohio Department of Alcohol and Drug Addiction Services The Ohio Department of Alcohol and Drug Addiction Services (ODADAS), in partnership with local level Alcohol, Drug Addiction and Mental Health Services (ADAMHS) and Alcohol and Drug Addiction Services (ADAS) Boards, provides community based treatment services to more than 34,000 Medicaid consumers annually. Ohio.s Medicaid program currently covers the following ten (10) treatment services provided in community settings: Ambulatory Detoxification, Assessment, Case Management, Crisis Intervention, Group Counseling, Individual Counseling, Intensive Outpatient, Laboratory Urinalysis, Medical/Somatic and Methadone Administration, through a network of ODADAS-certified treatment programs. The Ohio Department of Health The Ohio Department of Health (ODH) is responsible for enforcing health and safety standards in nursing facilities, residential care facilities and adult care facilities. The Division of Family and Community Health Services supports families and individuals to maintain their health status and remain active. The Bureau for Children with Medical Handicaps (BCMH) supports children with special healthcare needs and their families by providing access to medical services, local coordination of services by public health nurses and supporting the medical home concept. The Ohio Rehabilitation Services Commission The Ohio Rehabilitation Services Commission (RSC) operates on a 3.69 to 1 federal/state match funding structure and provides job training and employment retention services and supports to individuals with disabilities. For individuals unable to work, the Bureau of Disability Determination (BDD) determines eligibility for Social Security disability benefits or Supplemental Security Income. RSC also administers the Personal Care Assistance program for Ohioans with disabilities and supports the Statewide Independent Living Council, the Traumatic Brain Injury Advisory Council, the Community Centers for the Deaf, and the Governor.s Council on People with Disabilities. Ohio Department of Education The federal Individuals with Disabilities Education Act (IDEA 2004) requires, by law, that all children with disabilities in public Local Education Agencies (LEAs) have secondary transition plans as part of the Individualized Education Program (IEP) process beginning no later than age 16, or earlier if appropriate. This includes related secondary transition services and measurable post-school goals in the areas of employment, education and training, and independent living. The Department of Education is committed to continuously improving secondary transition planning for children with disabilities, parents, families, educators, and other stakeholders under the requirements in the IDEA 2004 and applicable Ohio law and rules. Ohio Department of Insurance The Ohio Department of Insurance (ODI) provides consumer protection through education and regulation while promoting a stable and competitive environment for insurers. Private long-term care insurance is an important, and growing, option for funding care. The department has staff available to answer questions about long-term care insurance and publishes a Shopper.s Guide to Long-Term Care Insurance. V. STRATEGIES TAKEN TO MOVE TOWARDS REBALANCING OHIO’S LONG-TERM SERVICES AND SUPPORTS SYSTEM (2007-2009) To adhere to Olmstead, Ohio has implemented the following policy changes to achieve an appropriate balance between Medicaid home and community-based care and Medicaid institutional settings. A. Nursing Facility Policy Changes 1. Nursing Facility Reimbursement Changes in House Bill 1 . In H. B. 1, Ohio continued the implementation of the pricing model that began four years ago with H.B. 66. To assist with alleviating the economic strain this strategy may impose on several nursing facilities, the General Assembly created a workforce development incentive payment. Additional services were also bundled into the nursing facility per diem. The additional funds from the bundled services create an incentive for efficient use of limited resources. 2. Certificate of Need (CON) Changes in House Bill 1 . The Certificate of Need (CON) amendments in H.B. 1 allow the Director of Health to periodically assess the need for nursing facility beds and allow for transfers of beds between counties in order for bed supply to match population migration. The calculation of bed need will focus on target occupancy and should adjust as community options are developed. Moreover, a nursing facility that has agreed to sell licensed beds in a county with bed excess to a facility in a county with bed need must surrender 10% of the beds they are selling to the state at no cost. The revisions to CON law will also allow the relocation of licensed nursing home beds from an existing nursing home to another existing nursing home located in a contiguous county. 3. Pre-Admission Screening and Resident Review (PASRR) Changes Pre-Admission Screening and Resident Review (PASRR) is a federally mandated screening process for individuals who are admitted into a nursing facility. The intent of this federal mandate is to assure the appropriate placement of individuals known or suspected of having a mental illness or developmental disability to receive the appropriate level of care necessary to meet their needs. . In the past two years, an inter-agency work group was convened to review the role of PASRR in meeting the Olmstead mandate, to ensure that individuals who are elderly and/or disabled are not institutionalized inappropriately. EMMA provided guidance to the work group and reported the work group.s progress to the EMMA Council. . The inter-agency work group analyzed PASRR-related rules and proposed revisions that intend to tighten Ohio.s PASRR system to reduce the likelihood of inappropriate and unnecessary institutionalization and transition individuals into the appropriate community alternative. One component to the changes to PASRR policy includes the collection of data to study the barriers to community placement as well as the referral mechanism to the HOME Choice Transition Program and the Area Agency on Aging Long Term Care Consultations. ODJFS is entering into a Money Follows the Person sub-grant agreement with Scripps Gerontology to study the impact of PASRR changes on access and quality of care and provide analyses to Ohio agencies on diversion and transition activities. . In addition to these PASRR changes, ODMH has partnered with ODJFS to utilize the Money Follow Person grant, which is being administered by ODJFS (HOME Choice) to help transition individuals who are elderly and/or disabled from institutions to alternative community settings. The principal focus is to use PASRR data to clinically identify nursing facility residents who may need to reside in a more appropriate setting to address their clinical mental health or developmental disability needs. These individuals are screened for eligibility in the HOME Choice program, and once approved, they are referred to a transition coordinator to initiate discharge planning to an appropriate community alternative. 4. Level of Care (LOC) Changes . A LOC assessment is required when a person is seeking Medicaid payment for certain services. Changes to Level of Care are driven by the need to assure greater flexibility and choice in service delivery and are based on data obtained through an ODJFS contract with Permedion, a provider of health care quality and analysis. Permedion performed a study of nursing facility level of care in 2009 and is embarking on a study of the ICF/MR level of care expected to conclude in 2010. The data gathered through these two studies will inform policy change. . The Inter-Agency Work and the Front Door Stakeholder Group (a group comprised of consumers/advocates, local delivery systems, and providers) will focus attention in 2010 and 2011 on changes to Ohio.s Medicaid Level of Care policy and operations. Level of care is a utilization management tool used by Medicaid to determine an individual.s level of disability and the appropriate level of care/services the individual requires. B. Implemented HOME Choice: Ohio’s Money Follows the Person Transition Program In January of 2007, Ohio was one of 31 states to receive funding for the “Money Follows the Person” demonstration project enacted by Congress as part of the Federal Deficit Reduction Act of 2005. Ohio, the fourth largest grantee, could potentially receive up to $100,645,125 in federal matching funds over five years. The grant has two core goals: 1.) Transition Medicaid recipients from facility based (also known as institutional) to community-based settings; and 2.) Create a foundation for long-term services and supports system change to better meet the choices and needs of persons who are elderly and/or have disabilities. The demonstration period concludes September 30, 2011; however, recipients enrolling in 2011 will receive benefits into 2012. The Ohio HOME Choice Transition Program adds “fuel” and a coordinating function to Ohio.s existing community system. In addition, Ohio.s Transition Program creates a distinct set of “post-institutional” services that smooth the way for people who are moving to a home setting from an institution. These extra services are finite as people adjust to living in their own homes and transition to individualized service packages established either through an existing HCBS waiver or Ohio Medicaid.s state plan benefit plus other services and supports that are not funded via Medicaid. The HOME Choice Transition Program provides insight and opportunity for analyses on the barriers to community placement for specific groups of people with disabilities, a necessary component to system reform. The program provides an opportunity to understand the changes needed to assure flexibility and choice for Ohioans. As of December, 1, 2009, the transition program has helped 360 Ohioans transition home with targeted outreach to persons with mental illness and children in residential treatment facilities. Please visit http://jfs.ohio.gov/OHP/consumers/homechoice.stm for information on Ohio.s Transition component known as HOME Choice (Helping Ohioans Move, Expanding Choice). A key component of the grant is system reform. The Ohio grant, using reinvestment dollars, includes strategies to reform the long-term services and supports system within all eight components of a balanced delivery system: housing, workforce, services, quality, self-direction, access (also known as the front door), organization and institutional supply controls. Please visit http://jfs.ohio.gov/OHP/infodata/ MFPGrant/info.stm for more information. The interagency team continues to work with stakeholders to reform the long-term services and supports system by: . Revising PASRR rules; . Revising Level of Care criteria; . Creating and funding a Consumer Council; . Building the web-based State Profile Tool; . Developing a health and human service lattice; . Developing a toolkit for Medicaid Housing; and . Expanding Permanent Supportive Housing. Success Story “Thank you so much for all your help. I can.t put into words how grateful I am. HOME Choice has given me my life back. My faith and hope-I thought I lost forever. HOME Choice is a program I would tell anyone that is in need or ready to make that step back to independent living again. On my move-in day I couldn.t believe it was true: I have my own apartment” --CM C. Ohio continues to add more self-directed services within Medicaid Waivers ODJFS plans to add the home care attendant service to the Ohio Home Care Waiver and the Transitions Carve-Out Waiver in 2010. As a result, consumers will have the ability to hire, train and direct unlicensed individuals who will provide them with assistance with the self-administration of medications and the performance of certain nursing tasks. The addition of home care attendant services is a result of the work of ODJFS staff, consumers, caregivers, providers and other advocates, as well as the enactment of H.B. 1. ODJFS has begun to modify the Transitions DD Waiver to better meet the needs of persons with developmental disabilities. New services are likely when the waiver is renewed in 2010. D. Unified Long-Term Care Budget Workgroup Ohio has provided a venue for stakeholders to influence system reform through the Unified Long-Term Care Budget Workgroup. The following recommendations were addressed in Am. Sub. H.B. 1. a. Elimination of the 1,800 participant limit for the Assisted Living Waiver in Ohio law; b. Expansion of Choices from a geographic pilot to the entire state of Ohio; c. Addition of new services to address the need for long-term services and supports in affordable housing – includes a new enhanced community living service which would be added to PASSPORT and adult foster care; d. Authorizes the combining of ODA.s three waiver programs into a single consolidated aging waiver; e. Authority to further expand long-term care consultation services to more effectively follow Ohioans placed in nursing facilities; f. Expansion of Home First enrollment to include PACE; and g. Reauthorized the existence of the workgroup for another biennium. E. Restructured Ohio’s Developmental Center and Home and Community-Based Setting Capacity Ohio has maintained its commitment to community living for individuals with developmental disabilities. Since 2006, Ohio has significantly increased the number of Individual Options waivers by 3,418 participants or 29.4 percent and Level One waivers by 3,033 or 90.7 percent. Ohio has reduced the total number of State-run Developmental Center beds by 181 or 11.3 percent. By May 2010, Ohio plans to eliminate another 54 beds bringing the total number of State-run Developmental Center beds to 1,370. F. Increased budget for developmental disabilities waivers. Ohio continues to increase the amount of the budget dedicated to waivers for consumers with developmental disabilities. There has been a steady increase in the percentage of total dollars committed to Medicaid Waivers: a 10.72% increase from 2007-2008; a 12.28% increase from 2008-2009; and despite a reduction of 8.85% in state GRF for FY 2010, waiver expenditures increased by 18.51%. Projections for FY 2011 show the pattern continuing with an 8.5% increase. Percentage of funding for the Developmental Centers has dropped 1.68% from 2007 to 2010, with projections showing another drop of 3.25% from 2010-2011. G. Regional Resource Centers Ohio has established Regional Resource Centers to prevent long-term admissions and to help individuals be successful in the community Since 2006, over 54% of all admissions to the Developmental Centers have been short-term (90 days or less) and as of 2009, over 81% have been short term. The Developmental Centers have been active in the prevention of long-term admissions through the following measures: . Providing technical assistance to County Boards regarding behavioral interventions; . Offering 90 day admissions for medical and behavioral stabilization; . Working with Probate Courts to encourage voluntary as opposed to involuntary admission; . Providing at least one year of “follow-along” services to all individuals leaving the Developmental Centers to assure successful transition to the community; . Providing training to families regarding the various waiver options; and . Opening all center-based staff training to community residential providers to assist them in improving their skills and services. H. Created the Medicaid in School Program Under the Individuals with Disabilities Education Act (IDEA), public schools are mandated to provide specific healthcare benefits to children with special needs, as needed, to assure that the child can benefit from their education. Specifically, public schools are required to provide a free appropriate public education, special education and related services, to children ages 3 through 21. Such related services can include therapies, nursing, counseling, etc. This mandate, as well as the requirement that children of compulsory age be enrolled in school, makes the school a great setting to facilitate healthcare access for children. House Bill 562 created a mechanism for federal reimbursement, for specific healthcare benefits, to be paid for by Medicaid, through an agreement between the Departments of Job and Family Services and the Education. Medicaid allows for reimbursement to the schools for some services provided, if the services are included in an Individualized Education Program (IEP) of a Medicaid eligible child. These are not additional services provided to a child, as the school is mandated to provide the service regardless of the availability of Medicaid funds. Therefore, the Medicaid reimbursement to the schools for these Medicaid allowable services alleviates some financial pressure for the schools that are a result of the cost of providing the IDEA-mandated services. In autumn of 2009, following collaborative process of working with the schools and stakeholders, changes to this program were implemented. Currently over 400 school districts and community schools have enrolled. Almost 300 schools are submitting and receiving Medicaid reimbursement for services delivered to over 26,000 children. In light of the enhanced federal funds available through ARRA, the schools are also receiving this enhanced funding. Efforts to inform and enroll school districts as Medicaid providers through the MSP will be continued. In addition, the MSP will continue to be monitored and adjustments made to improve efficacy in an effort to improve service access and delivery. I. Implemented the Ohio Secondary Transition Improvement Grant (OSTIG) The Ohio Secondary Transition Improvement Grant (OSTIG) initiative, a five year partnership grant (2007 through 2012) from the U.S. Department of Education, focuses on the coordination of secondary transition services for students with disabilities between the Ohio Rehabilitation Services Commission (ORSC) and the Ohio Department of Education (ODE). The outcomes of the work include: 1) Development of Transition Quality Indicators for transition planning improvement; 2) State-wide capacity building and training of regional teams to improve transition planning between school and adult services; 3) Identification of successful evidenced-based practices for seamless connection of transition planning and services; 4) State-wide replication of evidenced-based practices; and 5) Development of Regional Transition Councils representing all stakeholders in youth school-age to adult living transition process. Regional training and technical assistance for transition services and planning is provided to school professionals, students and families through the ODE.s 16 Regional State Support Teams. This training includes the Individualized Education Program (IEP) process, specific secondary transition elements, student and family self-advocacy and involvement, and connecting to adult service agencies. Through funding support from the ODE Office for Exceptional Children (OEC), the Ohio Coalition for the Education of Children with Disabilities (OCECD) provides parent and student training events related to the secondary transition process. With state and federal funding, the OCECD maintains a group of highly trained and qualified Parent Mentors across the state who are available to assist parents and families in the transition planning and implementation process, including connection to adult and community services. J. Implemented Ohio’s Medicaid Buy-In for Workers with Disabilities (MBIWD) Program In April 2008, the Ohio Rehabilitation Services Commission estimated that more than 2 million, or one in five Ohioans, have disabilities. However, the vast majority of Ohioans with disabilities are unemployed. In fact, the employment rate among Ohioans with disabilities is 37 percent compared to 80 percent for workers without disabilities. Many individuals with disabilities want to work and may have opportunities to work, but don.t pursue them for fear that increasing their income and savings might cause them to lose their Medicaid health care coverage. The Medicaid Buy-In for Workers with Disabilities (MBIWD) program was authorized in Amended Substitute House Bill 119 the 2008-2009 biennial budget. The program allows workers with disabilities to maintain Medicaid coverage while they are working earning income and establishing savings. After income deductions, MBIWD enrollees may earn up to 250 percent of the federal poverty level. Participants may also accrue savings of up to $10,000, a threshold which will be adjusted annually. MBIWD participants with incomes above 150 percent of the federal poverty level may pay a monthly health care premium for their Medicaid coverage. MBIWD encourages and supports Ohioans with disabilities to work and be promoted without risking the loss of Medicaid health care coverage. Currently, over 3,500 consumers, between the ages of 16-64 years, are enrolled via this new eligibility category. K. Working towards Expedited SSI and Medicaid The Ohio Department of Mental Health initiated a pilot project in May, 2008, as part of its Transformation State Incentive Grant (TSIG), to address the issue of delays experienced by mental health consumers in the processing of SSI and Medicaid applications. ODMH has worked with the Ohio Rehabilitation Services Commission (RSC), the Social Security Administration (SSA), and selected pilot community mental health provider organizations to develop model procedures for the provider organizations to use in submitting medical evidence to RSC at the time the application is submitted. These procedures are only applicable to adults with severe and persistent mental illness. The results of the pilot showed that where the screening criteria are applied properly and where the procedures are followed, the project was successful in achieving the desired state of 15-20 day processing time at the RSC. The processing of the Medicaid application in this project relies on the SSI award to verify disability as opposed to the development of medical evidence by the county and state Medicaid programs. Following the conclusion of the pilot in June, 2009, ODMH has enrolled more than 25 additional agencies in this project. These additional agencies and the initial pilot agencies serve a majority of the adult clients in the state with severe and persistent mental illness. The expediting procedures have been incorporated into the development of the Benefit Bank SSI module, the first application in the country to automate the SSI process, including the development of medical evidence. This new tool is being piloted on several agencies and will be rolled out statewide in the future. L. Implemented Ohio’s Intensive Home and Community Based Treatment (IHBT) Grants SFY08- 09 As a component of the Access to Better Care (ABC) Initiative, these grants from ODMH were awarded to fifteen ADAMH or community mental health boards in partnership with a community mental health agency that provided intensive home and community based mental health treatment to youth with serious behavioral / emotional disturbances who were at high risk for out-of-home placement because of their behavioral and emotional challenges. The grants totaled $1.4 million dollars over eighteen months from January 2008 through June 2009. These grants served 394 youth and their families and, 86% of the youth remained in their homes and communities. The youth with school disciplinary problems decreased from 68% to 49%, and the youth getting passing grades in school increased from 65% to 77%. The number of youth arrested decreased by 50%, the number on probation decreased by 50%, and the number detained by law enforcement decreased by 47%. The number of youth experiencing functional impairments due to use/abuse of alcohol or drugs decreased dramatically: from 24% of the youth down to 4% of the youth. At the conclusion of services, the youth, parents and treatment providers reported significant decreases in the severity of problems, and significant improvements in the functioning of the youth who received IHBT services. M. Implemented Medicaid Access Improvement for Individuals Leaving Correctional Institutions Medical care for individuals in state operated facilities such as correctional institutions is ineligible for federal Medicaid reimbursement. Therefore, when an individual is released and needs medical care, behavioral health services or prescriptions, these services were not readily accessible to this population. As a result, in August 2008, the RoMPIR (Reinstatement of Medicaid for Public Institution Recipients) project was initiated at the request of Governor Strickland to explore the challenge of suspending rather than terminating Medicaid benefits so that individuals who had Medicaid when they entered an institution could quickly obtain medical coverage when released. This new policy provides for suspension rather than termination of Medicaid benefits for persons entering certain public institutions in Ohio. The policy is applicable to persons entering adult and youth correctional facilities, as well as state psychiatric hospitals, who are subsequently discharged within one year. The policy has been implemented on a manual basis, and will be automated before the end of calendar year 2009. With the manual process the Medicaid coverage is activated in about a week versus the previous process to reapply for Medicaid, which could take several months. The automated process will shorten this timeframe to less than 72 hours. As of November 2009, a secure web application is now available for institution staff to notify County Department of Job and Family Services. when an individual on Medicaid enters a public institution and when they are released. VI. BALANCING INITIATIVES IN PROGRESS (2010 AND BEYOND) Ohio.s plan recognizes that true choice and system balance is realized when changes are made to multiple points of the delivery system structure including, but not limited to: the entry point, assessment of need, budget, service and support access, provider access, care management, quality, continuity, and program integrity. In an effort to provide expanded choice, efficiency, and quality of care, to align with the Olmstead purpose, and in response to the advocacy of people with disabilities of all ages and their families, Ohio must balance its long-term services and supports systems to assure choice, reduce institutionalization and increase opportunities for people to live in the community. Ohio has an extensive balancing plan, as a part of the Money Follows the Person Demonstration Grant (HOME Choice), that includes initiatives in all eight components of a balanced delivery system. These eight components are: 1. Administration and Budget – a mechanism to coordinate policies and budgets to promote community opportunities; 2. Access points – a clearly identifiable organizational management process to assure access to a wide variety of community supports, ensuring people understand the full range of available options before receiving more restrictive services; 3. Institution supply controls – mechanisms such as Certificate of Need requirements that enable states to limit or reduce institutional beds; 4. Diversion and Transition from institutions – outreach to identify residents who want to move and assistance with their transition to the community; 5. Housing and Services – availability of support services in a range of options from mainstream single-family homes and apartments to integrated group settings for people who need 24-hour supervision or support; 6. Workforce – recruitment and training to develop a sufficient supply of providers with the necessary skills and knowledge to encourage consumer independence; 7. Self-direction – people who receive home and community-based services having primary decision-making authority over their direct support workers and/or their budget for supports; and 8. Quality – an effective system that: a) measures whether the system achieves desired outcomes and meets program requirements and b) identifies strategies for improvement. Listed below are some of the initiatives that state agencies are developing to better address the need of balance in Ohio’s long-term services and supports system A. Creation of the State Profile Tool In response to the advocacy of people with disabilities of all ages and their families, many states are balancing their long-term services and supports systems to assure choice, reduce institutionalization and increase opportunities for people to live in the community. As part of the balancing effort, some states - with the encouragement of the Centers for Medicare & Medicaid Services - are developing a profile of their long-term services and supports system. Ohio is building a profile in response to a recommendation through the Unified Long Term Care Budget Workgroup and through the Money Follows the Person Demonstration Project. A state long-term services and supports profile can provide policymakers and stakeholders with a high-level view of the long-term services and supports system, identify opportunities for improved coordination among programs and other health and social services, acknowledge successes, and identify service gaps. Ohio.s profile will be web-based and will include the following: 1. An executive summary of Ohio.s current system and an overview of performance indicators with a progress rating form; 2. Background information on Ohio.s system; 3. Current and future challenges faced by the system in Ohio, how Ohio has responded to challenges, and Ohio.s vision for the future; 4. How Ohio will monitor progress to include development and tracking of the indicators; 5. Each indicator and presentation of data within the eight key system components of balance; and 6. Summary chart of indicators and policy initiatives. Indicators will roll out in three phases based on data source availability as follows: i. Phase 1 Indicators (baseline established and populated to the webpage in 2010) . Indicator #1: Ratio of Medicaid Expenditures on institutional care vs. home and community-based care; . Indicator #2: Ratio of the number of individuals served in Medicaid funded institutional settings vs. individuals served in home and community based settings; . Indicator #3: Per member per month Medicaid expenditures (both acute and long-term); . Indicator #4: Percentage of occupancy of all long term care beds; . Indicator #5: Accessible and Affordable Housing; . Indicator #6: Ohioans with Disabilities in the Workforce; . Indicator #7: Improving Services and Supports for Ohio.s Children; and . Indicator #8: ODA, ODODD, and ODJFS Waiting List Count. ii. Phase 2 Indicators (baseline established and populated to the webpage in 2011 if determined appropriate following additional interagency work) . Indicator #9: Planning for the Future; . Indicator #10: Rate of Underinsured and Uninsured Ohioans; . Indicator #11: The proportion of participants with opportunity to self direct by program; . Indicator #12: Satisfaction with services and supports; . Indicator #13: Health Care Workforce; and . Indicator #14: Specialized Coordination: TBI, Autism, Co-Occurring DD/MI and MI/Drug and Alcohol Use. iii. Phase 3 (Phase 3 indicators are expansions to the Phase 1 and 2 indicators and/or additions based on state profile results) This phase could include: . Expand Indicators #1, #2 and #3 to include all public funding sources; . Expand Indicator #1 to include characteristics of Ohioans residing in pre- determined settings; . Expand Indicator #7 to include “high-fidelity” metrics for children between birth and 21; and . Expand Indicator #10 to include other funding sources – of particular interest might be use of private insurance trends. B. Creation of The HOME Choice Advisory Council The charge of the HOME Choice Consumer Advisory Council is to advise the state agencies, General Assembly members and interested parties, by providing a forum for input, education and development of consumer consensus on principles, standards and policy initiatives impacting the long-term services and supports system. The Council will address issues of access and entry into the delivery system, services and supports design and redesign, self-direction expansion, housing and health and human service workforce development and unified budget. The Council will also lead in encouraging expanded advocacy across disability groups and will provide support and guidance to local advocacy efforts. The Council.s first meeting will be in spring of 2010. C. Creating Ohio’s Health and Human Service Lattice At the foundation of Ohio.s long-term care system and our health and human service career pathways is a wide pool of direct service workers. The direct service workforce is composed of the primary providers of paid hands-on assistance to consumers of all ages with a chronic or recurring need for long-term services and supports. Direct-service workers provide an estimated 70 to 80 percent of the paid hands-on long-term care and personal assistance received by Americans who are living with disabilities or other chronic conditions. (Public Housing Institute, 2009) There are multiple occupational titles within and across sectors such as developmental disabilities, aging, physical disabilities and behavioral health. Additionally, the location of direct service work varies from the home, to nursing facilities, day programs, and hospitals, to name a few. The direct service workforce is segmented into four major subgroups, reflecting the different settings in which services are provided and the distinct service delivery and funding streams: . Nursing facility aides; . Direct support professionals; . Personal and home care aides; and . Home health aides. As we increasingly provide services in home and community-based settings, the roles of direct service workers become more complex, requiring specialized knowledge, skills and attitudes. To address this increased complexity and demand, Ohio is taking advantage of complementary long-term care, education and workforce development resources across state agencies to lead the implementation of a comprehensive and portable education and training system for direct-service workers across all settings. The term „lattice. is used to identify the lateral and vertical opportunities for development among direct service workers. The direct service education and training system will be the foundation of the Health and Human Service Lattice. The specialized education and training provided in this system will create opportunities for direct service workers to improve their ability to provide quality care and a quality life for long-term care consumers. And, for those who choose, opportunities will be available to develop the knowledge, skills and abilities needed to transition into the high-demand health and human service pathway occupations. The Ohio Departments of Aging and Job and Family Services partnered with multiple state agencies to develop an action plan using strategic resources to develop a health and human service lattice project. Strategic resources include, a grant application to the United States Department of Labor, Education and Training Administration for Health Care Sector and Emerging Industries; ODJFS apprenticeship and workforce investments, and Money Follows the Person sub-grant to a public university to lead research design and analyses. Funding will be used to implement a state-wide education and credentialing system for Ohio.s direct service workforce. This investment will launch a project that will provide credentials for workers and provide evidence that can be used to validate on-going investment of state and local funds to ensure direct service workers across sectors have access to adult basic education, support services and exposure to the health care environment so that they understand the opportunities that exist and have the skills they need to succeed in the health care sector.s education and training programs. D. Continue developing a Unified Long-Term Care System In H.B. 119, the fiscal years 2008-2009 operating budget, the Legislature charged the director of the Department of Aging to lead an inclusive workgroup, which consisted of members of the legislature, state agencies, and members of the stakeholder community, to develop a Unified Long-Term Care Budget (ULTCB). On May 30, 2008, after ten months of work, the group presented its recommendations to the Governor and the General Assembly. As the workgroup.s mission stated, the recommendations would “create a budget for long-term care services and supports that unifies the budgeting process for facility- based and home-based services that supports Ohio.s ability to accurately forecast expenditures for these services in future years.” Many of the recommendations require significant changes in technology, and implementation of the new Medicaid Information Technology System (MITS), as well as additional funding. Nonetheless, the framework has been designed and planning continues to implement the recommendations in four phases. The four phases of the ULTCB are as follows: 1. Phase one focuses on Ohioans who become eligible for Medicaid-funded long-term care services and supports because they need nursing facility equivalent care. This phase includes both nursing facility services and home and community-based “waiver” services administered by the Departments of Aging (PASSPORT, Assisted Living and Choices) and Job and Family Services (Ohio Home Care Waiver) that provide alternative to nursing facility care. 2. Phase two places emphasis on consumers receiving long-term services and supports through Medicaid state plan services offered by Ohio.s behavioral health system. 3. Phase three is substantially the “futures” initiative described herein and focuses on consumers who access long-term services and supports through Ohio.s developmental disability system. 4. Phase four recognizes that not all those using publicly funded long-term services and supports are eligible for Medicaid and so the focus here is on consumers accessing long-term services and supports through other federal, state, and local funding sources. E. Quality Management System Ohio enhanced the comprehensive Quality Management System to assure the health and safety of individuals with developmental disabilities, no matter where they receive services The Department of Developmental Disabilities utilizes a broad range of strategies designed to achieve quality and assure the health and safety of individuals being served by the County Boards, residential facilities and community service providers. These strategies include: 1. Accreditation County Boards of Developmental Disabilities, responsible for administering community service programs for persons with developmental disabilities, must be accredited by the DODD. The accreditation survey focuses on four domains: service planning and delivery, health/safety/welfare, rights, and administration. The accreditation period can range from one to five years depending on the level of compliance. 2. Licensure The DODD licenses 419 ICFs/MR, the ten Developmental Centers, as well as 714 community- based residential facilities. Licenses are granted for a one to three year time period based on performance of the provider. The focus of a Licensure review includes health/ safety, rights, managing personal funds, and service planning and delivery. 3. Provider Certification The DODD has a certification and regulatory process for providers outlined in rule. In addition to passing a background check, the rule requires most independent providers and direct services employees of agency providers to: a. Hold valid First Aid certification; b. Hold valid CPR certification; and c. Have completed eight hours of training in: serving individuals with developmental disabilities, individual rights, waiver services, Incidents Adversely Affecting Health and Safety, and Universal precautions for infection control. Beginning October 1, 2009, all initial provider certifications issued by the Department will be for a term of one year; all renewal provider certifications will be for a term of three years based on the results of a review by DODD staff. F. Improved qualifications for direct support staff Ohio developed and implemented a plan to increase wages, benefits, training, supervisory support, recruitment, and retention of quality direct support staff. The Futures Committee recognized the need to have a large pool of qualified, well-trained and competitively paid direct support staff so that individuals with disabilities and their families have good choices, quality care and the best chances for positive outcomes. To date, the following progress has been made: . The Professional Advancement through Training and Education in Human Services (PATHS) program developed several curriculum additions and is collaborating with the Ohio Center on Autism and Low Incidence to develop training regarding autism and behavioral supports. . The DODD has worked collaboratively to address several issues in its budget for fiscal years 2010- 2011. Included in this work is an amendment that specifies that recommendations for modifying the payment rates for providers of Home and Community- Based Services waiver services may include recommendations for modifying the method.s components that reflect wages, benefits, training, and supervision of persons providing direct care. G. Futures Waiver Ohio is Developing a flexible support waiver (known as the Futures Waiver) to address the needs of children with very challenging behaviors so that they may successfully remain in their family homes. The Department of Developmental Disabilities and the Department of Job and Family Services will be implementing a new flexible support waiver for children. This New Futures waiver is intended to assist children with intensive behavioral needs who are living in the family home. The waiver targets those individuals who exhibit behaviors which can make it extremely difficult to complete ordinary activities, such as getting ready for school, sitting down to a family meal, or even enjoying a recreational outing. Patterns of challenging behaviors might include, but are not limited to, intense tantrums, excessive activity levels, withdrawal, self-stimulatory or stereotypic movements (like rocking or hand-flapping), as well as more serious behaviors such as aggression toward others, destruction of materials, and injury to self. The waiver will offer participant-direction of services and supports, and will embrace an individualized and coordinated planning approach. The New Futures waiver creates possibilities for accessing interventions and supports that have a positive impact on the family.s quality of life in the home, educational environment, and community. H. Improving support and services for individuals with challenging behaviors Ohio is improving the support and services for individuals with very challenging behaviors so that they may remain successfully in their community. In addition to the new Futures Waiver and the enhanced role of the Developmental Centers as Regional Resource Centers, the Department of Developmental Disabilities has implemented the following initiatives aimed at achieving this goal: . The DODD and the Ohio Department of Mental Health have agreed to jointly fund a position responsible for coordinating, organizing, and leading efforts to serve individuals with a dual diagnosis. . The DODD launched the Positive Culture Initiative in September of 2008. This initiative is a call to action for the developmental disabilities field to shift away from a primary focus on behavior support and instead look toward developing a positive approach to all interactions with people receiving services through our system. This is a shift away from outward behavior toward the development and fostering of positive relationships. To date, the following progress has been made: o Over 3,200 service providers statewide have been trained in this new philosophy. o A statewide Behavior Support Advisory Committee has collected data on the number of aversive behavior support plans in place so that future progress may be measured. o The Behavior Support Committee has also created training guidelines for behavior support professionals along with related tools to assist them in maintaining standards of a positive culture. A Conveners Group has been assembled comprised of strong community leaders. This group is charged with the task of selecting others within their circles of influence who will come together to form Local Network Groups. Together they will instill local ownership around a vision of creating a positive culture that drives all decisions being made about services to people in Ohio. I. Adult Day Services and Vocational Habilitation Providers Ohio has expanded community choices by increasing the number of providers of Adult Day Services and Vocational Habilitation. Since the end of calendar year 2007, an additional 335 community providers have been certified to offer adult day support, vocational habilitation and/or supported employment for individuals with developmental disabilities. J. Provided employment assistance for Ohioans with disabilities The Ohio Rehabilitation Services Commission (RSC) assisted 50,418 Ohioans with disabilities in working toward their employment goals. In spite of higher unemployment and economic downturns, 7,322 Ohioans with disabilities obtained or retained competitive employment through RSC in Federal fiscal year 2009 (October 1, 2008-September 30, 2009). K. Employment initiatives The Office of Governor Strickland convened an interagency group in early 2008 to look at disability services and opportunities for service coordination across Ohio. From that large workgroup, five small workgroups were developed to concentrate on the following specific employment related issues for individuals with disabilities including: 1. Improvements in the Transition Plan process (focused on transition from school to work); 2. Improvements in the understanding of Medicaid buy-in; 3. Improvements in the process of serving people with disabilities through One Stops, particularly focused on people with mental illness and substance abuse issues; 4. Improvements in the integration of Vocational Rehabilitation counselors in Mental Health facilities; and 5. Increased access to the Rehabilitation Services Commission.s services for people with chronic disabilities, particularly people with developmental disabilities. In addition to the work that is underway in the workgroups listed above, listed below are programs that allow individuals the opportunity to work without losing their health care and that will assist individuals with locating employment. a. Improving Ohio’s One-Stop System The mission of the One Stop System is “to offer coordinated workforce development and direct customer service to employers and job seekers - at one accessible location - to promote ongoing regional economic development through effective partnerships.” Ohio.s One-Stop System consists of 90 sites throughout the state with at least one facility in each county. Facilities may be of a Level One or a Level Two status. A Level One status is a facility that meets minimal requirements for services: . A resource room with internet capability; . Ability to provide core employment and training services to the universal customer; and . A minimum of three separate resource and cost sharing partner agencies contributing to the site operations. A Level Two status is a comprehensive, full service site that has nineteen (19) mandated partners and provides a full array of core, intensive and training services. All sites are certified on a periodic basis by the state, currently through the Gold Standard Continuous Improvement Program (One- Stop System Quality Assurance and Certification). Included in this program are benchmarks and critical success factors that gauge the quality of services and of the facility being reviewed. The Gold Standard Program requires: (1) all sites being reviewed and approved for ADA compliance and this is done in partnership with the Ohio Rehabilitations Services Commission (ORSC), and (2) all sites are required to have a minimum of one fully functional ADA workstation, scanners with the ability to translate written materials, and interpretive services (TTY, Language Access). b. The creation of meaningful employment opportunities for individuals with developmental disabilities . The Futures Committee identified the following priorities to increase employment options for individuals with developmental disabilities: The collaboration with private and public entities to enhance employment options; maximize incentives such as Medicaid Buy-In, tax credits and wage options for employees and employers; and find ways to make community employment a priority and improve school-to-work transition. . The DODD developed a regional school-to-work transition model for young adults and selected two school districts, Claymont in Tuscarawas County and Huber Heights in Montgomery County, to participate. Work with the districts began in April 2009. Plans are underway to add a site in Toledo. Fifty-eight individuals per year will benefit from these three combined projects. . The DODD secured funds through a Medicaid Infrastructure Grant which will be used to train service providers to engage employers and to develop a Medicaid Buy-In tool kit. Funds will be used for benefits counseling and asset development. The DODD plans to award mini-grants to support projects that improve employment opportunities for people with disabilities. The DODD is working with the Governor's Office and other agencies to expand employment opportunities for individuals with disabilities. Initial work has focused on comprehensive data collection. L. Developing Permanent and Supportive Housing As the state of Ohio moves forward with reform of the long-term services and supports system, housing will play a vital role in providing persons with the freedom to choose to live in the setting of their choice. Governor Strickland understands that one of the reasons individuals remains in institutions is due to the lack of affordable and accessible housing. As a result, The Interagency Council on Homelessness and Affordable Housing (ICHAH) was established by Governor Strickland.s Executive Order 2007-08S, as signed on April 23, 2007. The mission of the ICHAH is to “unite key state agencies to formulate policies and programs that address affordable housing issues and the needs of Ohioans who are homeless or at risk of becoming homeless”. The ICHAH is further responsible for making recommendations to assist the Governor in “...devising and implementing a long-term plan to support affordable housing and to end chronic homelessness.” On September 30, 2008, the Council requested assistance from the Technical Assistance Collaborative (TAC) to assist in the development of a long term plan to support affordable and accessible housing for Ohioans with long term disabilities including those who are chronically homeless. TAC completed a thorough review and analysis of affordable housing and available Medicaid resources in Ohio and presented a report to the Council outlining a series of important recommendations including key steps to expanding permanent supportive housing. The Council approved the report on July 15, 2009. Since the adoption of the TAC report, new workgroups have formed to implement the recommendations approved by the Council. The workgroups are: . Permanent Supportive Housing (PSH) Policy Framework which includes adoption of common PSH principles, a uniform permanent supportive housing definition, goals to end homelessness, promotion of the ADA community integration goals affirmed in the Olmstead decision, and reduction of the reliance on expensive and unnecessary restrictive and segregated settings. The workgroup will develop models to leverage potential federal funding for permanent supportive housing and create new technical assistance tools (e.g. the forthcoming federal substance abuse mental health services administration permanent supportive housing toolkit). . Access to Medicaid Workgroup which includes a review of current policies affecting the partnership between housing and Medicaid. . State/Local Permanent Supportive Housing Workgroup which includes a 50/50 conceptual framework intended to highlight the necessary partnership between State and local entities to reduce the reliance of public funding on outdated and expensive models and practices for vulnerable persons leading to potential development of 5,000 permanent supportive housing units over the next five years. Ohio also provides support services to individuals not receiving waiver or institutional care, but living in homes across the state, either rented or owned. Ohio has a limited supply of accessible rental units. Public and private housing complexes that receive federal money are generally required to have five percent of their rental units accessible to people with mobility impairments and two percent of rental units accessible to individuals with hearing or vision impairments. However, the availability of these units to people with disabilities has declined due to inconsistent enforcement of accessibility requirements, as well as the fact that most publicly and privately subsidized housing complexes only admit the elderly. To begin addressing the need for more information for consumers on housing options, the Departments of Job and Family Services, Developmental Disabilities, Aging, the Ohio Housing Financing Agency and the Developmental Disabilities Council have worked together to create an online housing locator service to catalog available housing options. The Housing Locator, http://www.ohiohousinglocator.org/, allows Ohioans to search for available housing options in their area. According to the Social Security Administration, in 2008 Ohio received more than $475,378,000 for Social Security Disability Beneficiaries. There are 390,233 Social Security Disability Insurance (SSDI) Title II (including dependents) and 250,255 Social Security Supplemental Income Title XVI beneficiaries in Ohio. While programs, like the Low Income Housing Tax Credit Program, have worked to increase the number of accessible housing units, affordability continues to be a concern. Although there is insufficient information documenting the actual number of accessible housing units for people with disabilities in Ohio, estimates may be made about unmet housing needs based on the number of people with mobility and sensory impairments. The Low Income Housing Tax Credit Program, the largest source of funding for affordable housing in Ohio, awards tax credits to approximately 55 projects a year. Based on the credit market in 2009, only 30 to 40 projects may be funded. These projects target individuals or families who earn an average of 40 to 60 percent of the Area Median Gross Income and are thus unaffordable to most people with disabilities. Additionally, there is little information about the location of accessible units available among existing housing stock. Many developers of affordable housing do not include information about accessibility in their property lists. For this reason, in some communities, accessible units remain vacant, which reinforces the misperception that there is no unmet need for affordable and accessible housing units. State agencies are focused on working to improve collaboration with local public housing authorities and local housing providers. The current challenge is developing partnerships to leverage limited resources. Through the IACAH, improved efficiencies and enhanced communications are underway; however a more direct effort is needed to build partnerships at the local level. Through Ohio.s Money Follows the Person grant, Ohio plans to expend dollars to build local housing and services cooperatives to bring state leadership to local systems and build partnership to improve coordination and efficiencies. VII. PROGRAMS AND SERVICES FOR INDIVIDUALS WITH DISABILITIES ACROSS THE LIFESPAN Disability can occur at any age. Data indicates that elderly individuals are more likely to present one or more signs of disability. However, in the Cornell University 2007 Disability Status Report for Ohio, it states that a prevalence of disability can and does occur before birth. Ohio has taken great strides in developing multiple Medicaid home and community-based waivers to care for individuals who are elderly and/or have disabilities. The Strickland Administration has taken great strides to care for individuals who are low- income and eligible for Medicaid waivers, however, not all Ohioans who are disabled qualify for Medicaid. This portion of the plan highlights programs that are offered by the state to individuals who may or may not qualify for Medicaid services. A. ODADAS Fetal Alcohol Spectrum Disorder Initiative ODADAS. fetal alcohol spectrum disorder initiative is an intersystem collaboration and education initiative designed to raise public awareness about fetal alcohol spectrum disorder being a 100% preventative condition. Public service announcements have been produced and are available through the social marketing campaign component of the initiative. Ohio.s mission is to establish efficiency in state systems resource allocation, coordination of services and augmentation of available resources to address fetal alcohol spectrum disorder. The Fetal Alcohol Spectrum Disorder Steering Committee developed a strategic, implementation and evaluation plan to address the key findings. The plan has five goals: . Increase the availability of services for those already affected by fetal alcohol spectrum disorder and for parents and other caregivers; . Increase awareness regarding the risks associated with alcohol use during pregnancy; . Provide fetal alcohol spectrum disorder -specific education and training for agencies, organizations and professionals who provide services to children and families with or at risk of fetal alcohol spectrum disorder; . Adopt appropriate fetal alcohol spectrum disorder screening tools and protocols and increase access to screening; and . Create and implement a data tracking system to track fetal alcohol spectrum disorder risk factors, prevalence, and incidence in Ohio, and measure progress toward reaching the other four goals. B. Early Intervention Early intervention services focuses on supporting parents and caregivers in their own homes and communities, and in ways that are functional and fit into the everyday rhythms and patterns of family life. Early Intervention (Part C of IDEA) services must be delivered in a manner that supports these principles (family centered and supportive, integrated and functional, and within the child and family “natural environments”). To that end, the Ohio Department of Developmental Disabilities and the County Boards of Developmental Disabilities have been researching and providing trainings using the latest national research in evidence based early intervention practices. County Boards of Developmental Disabilities, which in 2008 contributed over $100 million of services to the early intervention system and directly served nearly 10,000 Part C eligible children and their families, are increasingly offering early intervention services in the family.s natural environments, including homes, childcares, parks, grocery stores, and libraries. Ohio is taking a leadership role in moving from a system that focuses primarily on the child, to one that focuses on the needs of the family in supporting the young child, and in providing those services through trans-disciplinary teams. C. Help Me Grow Help Me Grow is administered by the Ohio Department of Health. It is a coordinated, community-based infrastructure that promotes trans-disciplinary family-centered services for expectant parents, newborns, infants, toddlers and their families. It is supported by federal funds awarded to the Ohio Department of Health as well as state General Revenue funds. These funds are dispersed to the 88 counties of Ohio„s County Family and Children First Councils to implement this system of services for infants and toddlers in Ohio. The goal of Help Me Grow is to assure that newborns, infants and toddlers across Ohio have the best possible start in life. Local Help Me Grow programs provide services that: . Identify children with or at risk for developmental delays or disabilities; . Provide screenings for health, hearing, vision and development; . Provide parents with information about their child.s social and emotional development that lays the foundation for later school success; . Assure that parents have information on the importance of early childhood immunizations and routine pediatric health care; . Link children and their families with local services that support them in improving their child.s developmental and health status; and . Connect children at age three with appropriate services. Help Me Grow Part C Help Me Grow Part C serves children age birth through age two who have a developmental disability or developmental delay. Five areas of development are evaluated and assessed upon entry into Help Me Grow, which include cognitive (how infants and toddlers think and process information), communication (how infants and toddlers receive and express to communicate), physical, social/emotional (mental, behavioral, emotional health), or adaptive (how infants and toddlers do for themselves) developmental domains. In State Fiscal Year 2009 (July 1, 2008 – June 30, 2009), 27,107 children were served in the Help Me Grow Part C program. Help Me Grow At Risk The purpose of the Help Me Grow at Risk program is to provide home visiting services and to provide linkages to community supports for infants and toddlers and their families so as to prevent the children from developing developmental delays. In order to be eligible for the At Risk program, infants and toddlers must have at least 4 risk factors present. Most children became eligible for the At-Risk programming within Help Me Grow due to low income or demographics, for example: a parent has less than a ninth grade education, neither parent is currently employed, or there is only a single (i.e., separated, widowed, divorced, never married) parent caring for the child. In State Fiscal Year 2009, 35,081 children were served in the Help Me Grow at Risk program. Future Plans In his 2009 State of the State address, Governor Strickland laid out his vision for Ohio.s early childhood administrative structure, “To better serve our youngest learners and help them thrive in school and in life, we will unite all of our early childhood development programs and resources into the Department of Education. This comprehensive early childhood system will focus on the whole child and provide quality early learning and care while improving our efficiency and effectiveness”. The Center for Early Childhood Development (CECD) will be housed at the Ohio Department of Education. Help Me Grow is slated to move to the Center in the near future. Success Story A single immigrant woman began working with a bilingual Help Me Grow home visitor while in her second trimester month of pregnancy. Since the woman had not received any prenatal care, the home visitor linked her to a nearby clinic that provided prenatal care on a sliding fee basis and also offered free transportation to and from the doctor visits. As the woman progressed in her pregnancy, the home visitor began educating her on the items she would need once the baby arrived such as clothes, crib, diapers, etc. Using a small doll, the home visitor also taught the woman how to care for an infant by practicing how to bathe, feed, and play with the baby. The home visitor emphasized the importance of talking and singing to the baby as a way to bond with the newborn and encouraged the parent who was illiterate in two languages to look at picture books with the baby and to point out and name the pictures using her native language and dialect. The young woman had her child and with the continued support of the home visitor has demonstrated appropriate care and bonding with the baby. The baby is developmentally on track per recent developmental screening. Success Story Help Me Grow received a referral for a young boy recently diagnosed with autism. The family was overwhelmed about the potential 35-40 hours per week of intensive therapy and expense involved with the diagnosis. The Help Me Grow Service Coordinator was able to link the family immediately with a few local resources that would help off-set the cost of therapy, the County Developmental Department, and the Play and Language for Autistic Youngsters (P.L.A.Y.) program. The emphasis of these services is on training parents to engage the child and further their social and emotional development. After several months of working with the family, the child has transitioned from Help Me Grow but continues to make progress. D. Bureau for Children with Medical Handicaps (BCMH) BCMH promotes early identification of children with handicapping conditions and treatment of those children by appropriate health care providers. Major components of the program include: . Conducting quality assurance activities to establish standards of care and to determine unmet needs of children with handicaps and their families; . Promoting and supporting the concept of a medical home for all children with special health care needs; . Supporting service coordination for children with selected diagnoses; . Collaborating with and funding public health nurses and local health departments to assist in increasing access to care and coordinating services at the local level; . Funding services for the diagnosis and treatment of medically eligible conditions; and . Assisting families to access and utilize appropriate sources of payment for services for their children. For more information about this program please visit: http://www.odh.ohio.gov/odhPrograms/cmh/cwmh/bcmh1.aspx Success Story For years BCMH has supported quarterly meetings with young adults, in three locations in the state, to learn from them about the issues youth face as they transition to adult life. One of the BCMH Youth Advisory committee is a 25 year old young man from Cleveland. This young man has been working very limited hours at Cleveland Clinic in the patient registration office for the Rehab hospital. The young man has cerebral palsy and uses a wheelchair. He is on a home care waiver, but also receives some services from Department of Developmental Disabilities. Cleveland Clinic offered to increase the work hours, but the young man and his parents were afraid of losing needed medical benefits and wavier services. The family was not concerned with the diminishing of Social Security benefit, but knew that keeping Medicaid coverage and waiver services were a must for this young man. With the encouragement and assistance of BCMH staff, this young man received counseling and is now enrolled in Medicaid Buy-In program for workers with disabilities. This young man can work more, earn more and still maintain Medicaid services and his waiver. The real success of this story is this young man has moved to his own apartment, is a working productive member of society and is proud of his independence. E. Ohio’s Medicaid Programs and Services Medicaid for the Aged, Blind or Disabled (ABD) is available to certain Ohioans to assist with medical expenses. ABD health care coverage consists of the primary and acute care benefit package and long-term care if a person has the required level of care need. Covered services include prescription drugs, home care, doctor visits, hospital care, laboratory and x-rays, medical equipment and supplies, dental care, transportation, mental health, vision services, long-term care, alcohol and drug rehabilitation and other services. At the end of November 2009, more than 476,800 consumers were receiving healthcare benefits in this service category. HOME AND COMMUNITY BASED WAIVER ENROLLMENT UPDATE Since the initiation of Home and Community-Based Services (HCBS) waivers in Ohio in the 1980.s, enrollment, utilization of services, and total expenditures have continued to grow. The term “waiver” refers to an exception to federal law that is granted to a state by the federal Centers for Medicare and Medicaid Services. Waivers allow participants, who have disabilities and chronic conditions, to have more control of their lives and remain active participants in their community. As a result, waiver services have become an integral part of community service options for persons with disabilities, in Ohio. The number of individuals enrolled in HCBS waivers has increased from 35,232 in state fiscal year (SFY) 2001 to 66,764 in SFY 2008. In SFY 2008, expenditures for waiver services were $1.45 billion. Expenditures for waiver services, as a percent of total Medicaid expenditures, have increased from 6.4% in SFY 2001 to 17.8% in SFY 2008. Ohio provides Medicaid funding for eight waivers. These eight waivers are currently administered through the Ohio Department of Job and Family Services (ODJFS), the Ohio Department of Aging (ODA), and the Ohio Department of Developmental Disabilities (DODD). Each waiver targets unique population groups and serves these groups with a range of home care supportive services. The waiver program.s cannot cover room and board, but do offer supportive services within the community environment. Listed in the following table is an overview of Ohio.s waiver enrollment: Waiver Name Administering Agency Consumer Age Enrollment (As of November 2009) PASSPORT ODA 60+ 27,561 Choices ODA 60+ 481 Assisted Living ODA 21+ 1,757 Ohio Home Care ODJFS 59 and younger 8,454 Transitions DODD ODJFS All ages 2,834 Transitions Aging Carve-Out ODJFS 60+ 1,659 Individual Options ODODD All ages 15,326 Level One ODODD All ages 7,168 Total 65,240 1. WAIVER DESCRIPTIONS The ODJFS-Administered Medicaid waivers are the Ohio Home Care, Transitions and Transitions II Carve Out waivers. Ohio Home Care Waiver: Approved in 1998, the Ohio Home Care Waiver is a limited-enrollment, cost-capped program of home and community services for people with serious disabilities and unstable medical conditions who would be eligible for Medicaid coverage in a nursing home or hospital. The Ohio Home Care Waiver is available to consumers age 59 and younger with an intermediate or skilled level of care. The benefit package for this waiver consists of waiver nursing, supplemental transportation, emergency response, and home delivered meal services. Transitions: Approved in 2002, the Transitions Waiver is a limited-enrollment, cost-capped program of home and community services for people who are eligible for Medicaid coverage in an intermediate care facility for people with developmental disabilities (ICF). Only people who were originally enrolled on the Ohio Home Care Waiver and have an ICF level of care are eligible for the Transitions Waiver, and the waiver has the same services, providers, and method of operation as the Ohio Home Care Waiver. This waiver is currently closed to new enrollment, with the exception to those individuals who desire to relocate from an institutional setting through the HOME Choice (Money Follows the Person Demonstration Grant). Transitions Carve-Out: Approved by in 2006, the Transitions Carve-Out Waiver is designed to meet the needs of consumers who are age 60 and older. Eligibility criteria require having either an intermediate or skilled level of care need. This waiver is not open to new enrollees. An individual must first be on the Ohio Home Care Waiver and be “transitioned” to the Transitions Carve-Out Waiver program due to turning 60 years old. This waiver is currently closed to new enrollment, with the exception to those individuals who desire to relocate from an institutional setting through the HOME Choice (Money Follows the Person Demonstration Grant). ODJFS also delegates responsibility for administering certain waiver programs and specialized services to two other state agencies. This allows partner state agencies to receive federal revenue for eligible programs and services they administer for their target populations. The Ohio Department of Aging (ODA) administers the PASSPORT, Choices, and Assisted Living waiver programs. PASSPORT: Approved in 1984 and operated statewide since 1990, the Pre-Admissions Screening System Providing Options and Resources Today (PASSPORT) waiver provides services in home and community settings to delay or prevent nursing facility placement. PASSPORT serves individuals age 60 and older who have a nursing facility level of care and meet Medicaid financial eligibility standards. Services help preserve the independence of the individual, as well as maintain ties to family and friends. Choices: Approved in 2001, Choices is a consumer directed Medicaid waiver program that provides home and community-based services and supports to older Ohioans. Providers can be agency or non- agency professional caregivers or individual providers such as friends, neighbors or some relatives (spouses, parents, step-parents and legal guardians are ineligible). Choices serves individuals age 60 and older who have a nursing facility level of care and meet Medicaid financial eligibility standards. Choices is available to current PASSPORT consumers in the central Ohio, northwestern Ohio, and southern Ohio regions served by the Area Agencies on Aging based in Columbus, Toledo, Marietta and Rio Grande. Assisted Living: Approved in 2006, the Assisted Living program provides services in licensed and certified residential care facilities (RCFs) to delay or prevent nursing facility placement. Assisted living promotes aging in place by supporting consumer desire for independence, choice and privacy. The services help preserve the independence of the individual, as well as maintain ties to family and friends. Participants must be age 21 or older and be a current nursing facility resident or on an existing Medicaid waiver; or have lived in an RCF on private pay for at least six months, have a nursing facility level of care and meet Medicaid financial eligibility standards. Program of All-Inclusive Care for the Elderly (PACE) is not a Medicaid waiver, it is a managed care model that provides participants in specific geographic areas with all of their needed health care, medical care and ancillary services in acute, sub-acute, institutional and community settings. To be eligible for PACE, participants must be age 55 or older, live in the Cleveland and Cincinnati area and, if seeking Medicaid assistance, qualify for coverage under the institutional financial eligibility standards (participants can be private-pay) and have a nursing facility level of care. The Ohio Department of Developmental Disabilities (DODD) is responsible for care provided in Intermediate Care Facilities for the Mentally Retarded (ICF/MR), and administers the Individual Options and Level One waiver programs. Level I: Approved in 2002, the Level I Waiver is for people with mental retardation or other developmental disabilities who require the care given in an Intermediate Care Facility for the Mentally Retarded (ICFMR) but want to live at home and have a network of families, friends, neighbors and professionals that can safely and effectively provide the needed care. The cost for this help cannot be more than the Level I Waiver allows. Individual Options (IO): Approved in 1991, the Individual Options Waiver, commonly referred to as the I/O Waiver, is an enrollment-limited, cost-capped program that allows people with mental retardation or other developmental disabilities to receive supports necessary to stay in their homes and prevent the need to live in an Intermediate Care Facility for the Mentally Retarded (ICF/MR). F. Ohio Access Success Program Since 2004, the Ohio Access Success Program (Success Project) has expanded Ohio.s capacity to serve consumers with long term needs in the community by identifying individuals living in nursing facilities that want to live in a community-based setting and are able to do so safely and with proper linkages to community services and supports. After taking referrals in a five-county pilot area, the Success project went statewide in February 2005. As of December 2008, 1,402 people have been referred to the Success Project and 461 people have relocated to community-based settings with assistance from the project. Additionally, more than 300 nursing facilities, as well as a number of other social service agencies and nursing home provider organizations, have been educated about the Success Project. The Success Project directs those consumers who are ready to leave the nursing facility, but are unable to qualify for HOME Choice due to an insufficient length of time spent in nursing facility. The Success Project is also a valuable resource for those consumers who are not eligible for Medicaid when they leave the nursing facility or who do not need any waiver or home health services. G. Services provided under the Older Americans Act In addition to managing Ohio.s Medicaid HCBS waivers for older adults, ODA is also the designated State Unit on Aging for Ohio and thus receives funds pursuant to the Older Americans Act (OAA). Funds received under the OAA are matched with state general revenue funds from the senior community services and Alzheimer.s respite funding lines. While not all OAA services can properly be considered “long-term services and supports,” OAA funds are used for home-delivered meals, respite supports, home repairs, and transportation. Unlike Medicaid, there are no financial eligibility requirements to receive OAA funded services, though service recipients are asked to contribute a portion of the cost of each service on a sliding- fee scale basis (except for meals programs where such cost-sharing is prohibited by federal law). To be eligible, Ohioans must be age 60 or over. However, also unlike Medicaid, OAA funded services are not an entitlement and there is a waiting list for most services. ODA distributes OAA and related state funds to each AAA based on a population formula. The AAA is responsible for determining which services it will fund, the amount of funding for each service, and chooses service providers through a competitive process. In an effort to better target scarce OAA resources, AAAs have established care coordination programs where consumers benefiting from multiple programs and services also benefit by having a care manager. This enables AAAs to serve those most in need of multiple services by reasons of either economic or service need. The goal of these programs is to serve those who are “near eligible” for Medicaid funded long-term services and supports. Ohio is one of a few states with a specific statute that allows local communities (largely counties) to pass property tax levies in support of senior services. As should be expected, the levies vary greatly in scope of services and the amount of funding generated ranging from small amounts of funding dedicated to support a specific senior center to larger levies in urban counties that support a system of services and supports using the PASSPORT model. These larger levies tie eligibility to those not meeting the strict guidelines for PASSPORT enrollment. Enrollment may be managed either through an AAA or through a county office on aging. As of the November 2008 election, 69 Ohio counties (and several townships and villages) have passed senior services levies. The economic value of these levies is $136 million, double the amount of ODA.s OAA and state funding lines for non-Medicaid services. H. Ohio’s Independent Living Older Blind Program The Independent Living Older Blind Program, managed by RSC, serves persons 55 years of age and older who are blind or have a significant visual impairment in Ohio. The program serves persons whose recent severe visual impairment/blindness makes competitive employment extremely difficult to obtain, but for whom independent living goals are feasible. The program offers the following services/activities to persons in need of services. Services to help correct blindness, such as outreach services, visual screenings, the provision of eyeglasses and other visual aids, the provision of services and equipment to assist an older individual who is blind to become more mobile and more self-sufficient, mobility training, Braille instruction, and other services and equipment to help an older individual who is blind adjust to blindness, guide services, reader services, and transportation, any other appropriate service designed to assist an older individual who is blind in coping with daily living activities, including supportive services and rehabilitation teaching services. In addition, other independent living skills training, information referral services, peer counseling, and individual advocacy training may be provided under the program. In Federal Fiscal Year 2008 (latest available data), the program reported the following data: . Total expenditures and encumbrances for direct program services $1,093,220. . Total individuals served during the reporting fiscal year 2,972. I. Personal Care Assistance Program In 1981, the General Assembly enacted Am. S.B. 522 to establish the Ohio Personal Care Assistance Program, within RSC. The purpose of the program is to provide financial resources for personal assistance services to assist Ohioans with severe physical disabilities in the payment of wages for the provision of such services. Personal assistance services help a person with severe physical disabilities perform activities of daily living such as dressing, toileting, grooming, bathing, preparing food, feeding, turning, repositioning, transferring, giving medications, assisting with ambulation, etc. The program provides services based on four main priority groupings, with the emphasis placed on providing services to individuals who are competitively employed. Participants who are not competitively employed receive assistance on a time-limited basis as indicated in the Administrative Rules. Priority one is for services to those individuals who need personal assistance services to maintain competitive employment, including home-based employment and self-employment. Priority two is for services to those individuals who are actively seeking employment. Priority three is for services to those individuals who are in an active training program with a goal of obtaining employment once training is completed. Priority four is for services to those individuals who need assistance to maintain independent living outside of an institution and who do not meet the criteria for the other three priorities. This priority level is closed to new participants and/or transition of participants from the other priority levels. The Personal Care Assistance Program now includes 154 people with severe physical disabilities who are working, looking for work, or engaged in a training program. An additional 37 consumers are provided with funding to maintain their daily living activities. At present, there is no waiting list. Newly found eligible consumers will move into open slots immediately. J. Ohio’s Anti-Stigma Campaign The Ohio Department of Alcohol and Drug Addiction Services and the Ohio Department of Mental Health share an ongoing public awareness campaign entitled, “Think Outside the Stigma,” which aims to eradicate public myths and misconceptions about addiction and mental illness. A Stigma Reduction Committee spearheaded by the Ohio Department of Alcohol and Drug Addiction Services created the “Think Outside the Stigma” tagline and the tagline and four message points were tested by more than 200 focus group participants in September 2007. The following are the four key tenets from the initial 2007 campaign launch: 1) Alcohol and other drug addictions and mental illnesses are brain diseases; 2) Alcohol and other drug addictions and mental illnesses can affect anyone; 3) Alcohol and other drug addictions and mental illnesses are treatable; and 4) Individuals with brain diseases should not be discriminated against. In 2008, the campaign received Congressional recognition with a bipartisan resolution. In 2009, the Cleveland Clinic and Cardinal Health began partnering with ODADAS to disseminate information and materials related to the campaign. ODADAS will be airing, in 2010, a radio Public Service Announcement (PSA) on the campaign. K. Ohio’s Stigma Buster Eliminating stigma associated with mental illness and addiction is critical in ensuring that people seek treatment they need. The Ohio Department of Mental Health has supported Ohio NAMI in the national NAMI Stigma Busting Campaign. This stigma campaign seeks to build a network of dedicated advocates nationwide, including Ohio, who seek to fight inaccurate and hurtful representation of mental illness. They seek to educate society about the reality of mental illness and to break down barriers of ignorance, prejudice or unfair discrimination by promoting education, understanding and respect. The Stigma Buster includes a monthly electronic newsletter also. The primary purpose of the newsletter is to fight the stigma of mental illness by giving community leaders a forum to share their personal stories about how mental illness has helped improve their quality of life. L. Ohio’s Assertive Community Treatment (ACT) Ohio's mental health system provides Assertive Community Treatment (ACT) to approximately 2,300 consumers served by 40 teams which actively engage persons with severe mental illness to assist them in finding housing and meet other basic life needs including health care. Ohio also has several forensic ACT teams which provide services to persons who have been released from prison and have severe mental illness and substance abuse histories that lead to a high risk of homelessness. Additionally, the Columbus and Dayton areas each have three teams that combine two evidence based practices ---ACT and Integrated Dual Diagnosis Treatment (IDDT) -- which address the needs of consumers who have severe substance abuse and mental illness. Ohio provided IDDT services to 4,781 consumers in State Fiscal Year 2009. Ohio also has more than 30 mental health and substance abuse courts that offer treatment alternatives to incarceration that may lead to services that may prevent homelessness. Success Story WA attributes his success partly to a local recovery-based church that “gave me hope and brought me down to earth when I was unable to do it on my own.” WA had been gainfully employed for six months and was celebrating eight full months of sobriety, the last time the state checked in with him. M. Ohio’s Consumer Operated Services/Peer Support Organization and Consumer Benefits Package Initiative There are over 60 Consumer Operated Services/Peer Support organizations in Ohio. These organizations offer peer support in the community by way of: . Referrals to benefit counseling to assist with employment that will not affect consumers. benefits; . Wellness Recovery Action Plan (WRAP) training that educates peers on triggers and how to be pro-active when symptoms occur; . Bridges training to educate consumers on the system and their mental health diagnosis; and . Advance Directives training that allows consumers to prepare in advance how they want to be treated if they become ill and have to be hospitalized. All of these resources enable consumers to become self-directed in their recovery in the community. They promote empowerment and hope for many consumers who believed they could never live independently in their local neighborhoods. This enhances the efforts of the Olmstead Initiative by offering resources that provide the supports consumers need to integrate and be part of a community living independently. Also, ODMH has initiated a new project funded through the transformation grant that partners with Consumer Operated Services/Peer Support Leaders to achieve on-going sustainability for Consumer Operated Service centers. The Consumer Operated Service leadership will design and develop a toolkit and training curriculum to position Consumer Operated Service centers and Peer-provided services for inclusion in the benefit service packages. N. ODMH Housing Assistance Program Housing Assistance Program is a resource that assists persons with mental illness in obtaining permanent community housing. Local ADAMH Boards contract with a local provider to administer the housing assistance program. Often, the program provides a short-term subsidy for rental housing but it may also aid loan assistance and pay for start-up costs related to housing as well. When utilized as a rental subsidy, HAP acts as a “bridge” subsidy until a permanent subsidy (Section 8 Voucher) may be obtained, until a person.s income increases sufficiently so that a rental subsidy is not needed, or until a person can obtain the financial resources necessary to own their own home. HAP is used with housing that includes a standard landlord/tenant lease where there are no requirements for clinical treatment required as part of the lease. Additionally, housing assistance programs can also be used to support home ownership. O. ODMH Community Capital for Housing ODMH makes available state capital funds (bond revenues) which can be used for capital costs related to housing for persons with severe mental illness. ODMH partners with boards that may use these funds in accordance with their local capital plan, to purchase, renovate and/or construct housing for persons with mental illness. ODMH can fund up to 75% of the total approved costs of a housing project, and in turn places a forgivable mortgage on each capital project for a term not to exceed 40 years (this changes to 30 years beginning on July 1, 2010.) P. ODMH Match Funding for Ohio Department of Development (ODOD) Homeless Assistance Grant ODMH offers match funding to local providers applying through ODOD.s Homeless Assistance Grant for Direct Housing, Permanent Supportive Housing and Transitional Housing. To qualify for ODMH match dollars, the program must target persons with severe mental illness and must have local mental health board support. Due to funding limitations, applicants cannot request more than one-half of the ODOD local match requirement and no applicant can receive greater than $50,000 in match funding. Q. Match Funding for U.S. Department of Housing and Urban (HUD) Continuum of Care (CoC) Grant ODMH offers match funding for HUD CoC programs with capital costs up to $300,000. To qualify for ODMH match money, the program must target persons with severe mental illness and must have local mental health board support. Additionally, all such requests must be written into the local mental health board.s capital plan for the biennium in which the funding is being requested. R. Ohio’s Mental Health Housing Leadership Institute (MHHLI or the Institute) The Institute is funded by ODMH and operated by NAMI Ohio. The Institute provides free consultative services to local mental health boards and communities to assist them with both the planning, development and preservation of housing for persons with severe mental illness. NAMI Ohio was funded for this initiative through June, 2009. The Cooperation for Supportive Housing is currently being funded to provide these housing activities through 2010. S. Ohio’s Independent Living Centers The Ohio Statewide Independent Living Council (SILC) is committed to promoting a philosophy of consumer control, peer support, self-help, self determination, equal access, and individual and systems advocacy, in order to maximize leadership, empowerment, independence, productivity and to support full inclusion and integration of individuals with disabilities into the mainstream of American society. Established in 1992 by amendments to the Rehabilitation Act of 1973, the Ohio Statewide Independent Living Council (SILC) has eleven governor-appointed council members from Ohio.s disabilities community. The Ohio SILC is an independent agency created by the Governor.s Executive Order and legislatively recognized in the Ohio Revise Code 3304.50. The SILC and Centers for Independent Living is fiscally housed in the Ohio Rehabilitation Services Commission budget at the Governor.s discretion. The Centers for Independent Living are community based, consumer controlled, not for profit organizations that serve persons of any age with disabilities in approximately 40 counties in Ohio. The Independent Living Centers focus on housing, transportation, access surveys, assistive devices, youth, voting, and general information efforts. Centers support individuals in returning to the community who no longer wish to reside in a nursing facility. Future Plans . Council.s for Independent Living Centers are actively pursuing ways to provide independent living services to areas of the state at present not covered by a center; and . Independent Living Centers are developing relationships with state Area Agencies on aging through a grant to the Ohio Department of Aging to provide independent living services to assist Ohioans with various disabilities to remain in the community rather than needing to turn to costly nursing facility care. T. Ohio’s Projects for Assistance in Transition from Homelessness (PATH) ODMH administers the Substance Abuse and Mental Health Services Administration (SAMHSA) PATH program. PATH is a formula grant program which seeks to eliminate homelessness for people with serious mental illness by connecting persons currently unknown to the mental health system to mental health services. In addition, a small percentage of PATH funds can be used to pay for housing costs (e.g. first month.s rent or security deposit). Eleven counties in Ohio have PATH programs which provide outreach services to this population. Most PATH programs are located in urban communities within the state. DODD Capital Housing: The Ohio Department of Developmental Disabilities (DODD) makes available state capital assistance (bond) funds to assist local County Boards of Developmental Disabilities in purchasing housing for individuals receiving Supported Living services, or Supported Living services funded through Home and Community Based waivers. The goal of the program is to provide housing options in their own communities that allow people with disabilities to be as fully integrated and independent as possible. U. Expanding community living options Ohio received Community Capital Assistance dollars for County Boards to expand community living options through the purchase and renovation of existing homes. The Department of Developmental Disabilities makes available state capital assistance (bond) funds to assist local County Boards of Developmental Disabilities in purchasing housing for individuals receiving Supported Living services, or services funded through Home and Community Based waivers. The goal of the program is to provide housing options in their own communities that allow people with disabilities to be as fully integrated and independent as possible. The process for accessing Capital Housing dollars is governed through DODD administrative rule 5123:1-1- 03. Typically, County Boards of Developmental Disabilities establish non-profit housing corporations to receive the funds, and match them with other funding sources. Existing homes in the community are then purchased with these dollars for individuals with developmental disabilities, often with their active involvement. Capital housing dollars are allocated to counties through an established formula based on available funds. The funds can be used to purchase, renovate or provide environmental modifications to make the homes more accessible. The 2007 Martin Settlement called for the expansion of community residential services for individuals who are disabled. As a result, the Martin Settlement set aside additional dollars from the Capital Budget for distribution to county boards of developmental disabilities for participation in the Capital Housing program. . Housing Purchases Expenditure since FY 2007 is $4,843,725.00; . Accessibility Expenditures since FY2007 is $476,247.00; . Renovation Expenditures for FY 2009-2010 are $311,185.00; and . Martin Housing and Renovation Expenditures to-date $7,977,487.00. V. Ohio’s Supported Employment Coordinating Center of Excellence The Ohio Supported Employment Coordinating Center of Excellence (Ohio SE CCOE) was created in July 2005 as a partnership between Case Western Reserve University and the Ohio Department of Mental Health. The Ohio SE CCOE is a technical-assistance organization that promotes knowledge development and the implementation of evidence-based practices (EBPs) for the treatment and recovery of people with mental illness. Evidence-based practices are service models that research has demonstrated to generate improved consumer outcomes, program outcomes, and service systems outcomes. Research shows that organizations which maintain fidelity to the original design of Supported Employment (SE) achieve and sustain the best outcomes. The SE CCOE helps service systems, organizations, and providers implement and sustain the SE model, maintain fidelity to the model, and develop collaborations within local communities that enhance the quality of life for consumers and their families. The SE CCOE is providing technical assistance for SE to community mental health agencies throughout the State of Ohio which are located in a variety of communities (e.g. urban, suburban, and rural districts). SE is an evidence-based practice that helps people with severe symptoms of mental illness identify, acquire, and maintain competitive employment in their communities. SE is assertive about helping people find the work they want as soon as they express the desire to work. The model facilitates systems change, organizational change, and clinical change. There are seven core principles that make the evidence-based Supported Employment model different from other vocational programs: . Zero Exclusion Policy; . Consumer Preferences; . Rapid Job Search; . A Competitive Job is the Goal; . Employment is Integrated with Mental Health Services; . Time-Unlimited Support; and . Personalized Benefits Planning. Between July 1, 2006 and December 31, 2009, 1,714 persons with severe and persistent mental illness have achieved competitive employment as a result of participating in an evidence-based Supported Employment program at a community mental health agency. W. Business Enterprise Program The Business Enterprise Program (BEP) administers the federal Randolph-Sheppard Act for the purpose of providing entrepreneurship opportunities for persons who are blind. Ohio.s BEP has 114 businesses statewide with 112 licensed operators managing these businesses. Gross sales generated from these businesses were $18,068,007 in FFY 2009 and the average licensed operator reported an income of $42,311. Future Plans: . Operators using the Ohio Business Gateway Electronic reporting for sales, profits, and program payments replacing paper filings and reducing staff time; . Web based program training for licensure of eligible consumers; . Increase in the number of businesses in the program through expansion into additional University and College Campuses; and . Exploring new business ventures. X. Ohio’s Long Term Care Insurance Partnership It is important for all Ohioans to understand the need for planning for future long-term care needs. In Ohio, the average cost of long-term care is as follows: . $67,058/year for a private room in a nursing home; . $60,251/year for a semi-private room in a nursing home; . $29,738/year for care in an assisted living facility (private, one bedroom); . $51,714/year for a license, Medicare-certified home health aide (50 hours per week); and . $44,122/year for homemaker services (50 hours per week). The assumed average stay in a nursing home is 2.5 years. The average length of time for informal or custodial care in the home is 4.3 years. The Ohio Department of Insurance partnered with the Ohio Department of Job and Family Services to develop the Ohio Long Term Care Insurance Partnership (effective September 2007). To encourage long term services and supports planning, Ohio entered into a cooperative agreement with the U.S. Department of Health and Human Services (HHS) “Own Your Future” Campaign in December 2007. Governor Strickland announced the campaign through a public release followed by radio announcements and a series of forums around the State in the Spring/Summer of 2008. The Ohio Long Term Care Insurance Partnership was created to encourage Ohioans to plan for their long- term health care needs. If an Ohioan purchases a qualified partnership policy, they will gain coverage for long-term care services which will provide them with choices about their long-term care. Ohioans without a partnership policy who need Medicaid long-term care services must deplete almost all of their assets to qualify for the Medicaid program. Visit http://www.ltc4me.ohio.gov for more information about Ohio.s long- term care partnership program. The Ohio Long Term Care Insurance Partnership initiative continues. Outreach about the initiative occurs continuously through various sources. The Ohio Senior Health Insurance Information Program (OSHIIP) continues to provide information on the Partnership program. The Ohio Department of Job and Family Services (ODJFS - Medicaid) provided training and outreach materials to OSHIIP during this reporting period. ODJFS-Medicaid also provided training in June 2009 to County Departments of Job and Family Services eligibility staff. VIII. FEDERAL HEALTH CARE REFORM AND LONG-TERM SERVICES AND SUPPORTS Ohio.s long-term care strategies are obligated to operate in the context of federal policy. For example, Ohio, like most states, has struggled to balance its efforts to improve community long-term care options with the institutional bias in federal Medicaid policy. The federal Centers for Medicare and Medicaid Services (CMS) has to approve the Medicaid waivers that fund a significant portion of home and community-based long-term care programs in Ohio. Moreover, one requirement imposed in states is that these programs must be budget neutral compared to institutional care. Thus, changes at the federal level can greatly impact state strategies, in both positive and negative ways. Health care reform, if passed, will result in the most comprehensive change in both federal and state health care policy in decades. The legislation would require a major expansion of the Medicaid program, and also includes several provisions to promote and support state efforts to increase access to home and community-based services. Below are several examples of the long-term care provisions in the House, Senate Finance and Senate Health Education, Labor and Pensions committees as of November 12, 2009. . Creates a new office within CMS responsible for coordinating care for dual eligibles, and provides a five year Medicaid demonstration authority to states to coordinate care for dual eligibles. . Extends the Money Follows the Person grant for an additional five years, to 2016 and modifies the length of stay eligibility requirement from 180 days to 90 days opening the program up to additional persons in institutional settings. . Allocates $50 million over five years to continue the Aging and Disability Resource Center initiatives. . Allows states to offer home and community based services through a state plan amendment (SPA) rather than a waiver, for individuals with incomes up to 300% of the maximum SSI payment. . Provides a targeted increase in the federal Medicaid match rate for five years to states that undertake reforms to increase nursing home diversions and access to community based services in their Medicaid programs. . Establishes the Community First Choice Option in Medicaid to provide community-based attendant supports and services to individuals with disabilities who require an institutional level of care. This option would provides states with an enhanced federal match rate of up to an additional six percentage points for a five year period for reimbursable expenses. . Establishes the Community Living Assistance Services and Supports (CLASS) program, a national, voluntary insurance program that will provide participating individuals with functional limitations a cash benefit to purchase non-medical services and supports necessary to maintain community residence. The program would be fully-financed through voluntary payroll deductions. While it is still unknown how many of these provisions will be included in the final bill, this does give us a sense of the intention of Congress that individuals should have access to services in their communities. These tools do not solve some of the fundamental barriers states face, but they will be helpful in Ohio.s efforts to provide the right care in the right place at the right time for Ohio.s elderly and disabled populations. IX. CHALLENGES As mentioned earlier in this Plan, the Operating Budget for State Fiscal Year.s 2010-2011 was developed during one of the most devastating economic downturns in recent history. Strategic funding mechanisms were introduced to balance the budget, as Ohio is required to operate on a balanced budget pursuant to the Ohio Constitution. A substantial increase in federal Medicaid assistance (FMAP) enacted through the American Recovery and Reinvestment Act (ARRA) enabled the Medicaid agencies to avoid cuts in benefits or enrollment for this biennium and helped to sustain community supports. However, as described below, several agencies experienced reductions in state funding. And all of the agencies are now already in the planning stage for the next biennial budget driven in part by the assumption that the increased FMAP will not continue. Listed below are some of the challenges agencies are currently experiencing while striving to appropriately balance Ohio’s long-term services and supports system: The Department of Job and Family Services: According to Mathematica, the national evaluator of the Money Follows the Person demonstration, all but four of the 30 participating states have experienced difficulty in meeting their targets for enrollment in their MFP demonstrations. There are a variety of factors related to this difficulty: some statutory (such as the requirement that participants be institutionalized for at least six months); some are design-related (for example assisted living settings do not qualify); and some are due to the difficulty of the transition itself (primarily due to the lack of suitable housing alternatives). The state agencies involved in HOME Choice are currently revisiting their original enrollment projections to develop more realistic targets going forward. The Department of Aging implemented several key recommendations that were made by the Unified Long-Term Care Budget Workgroup in the H.B.1; however there are recommendations that could not be implemented during this current economic climate. Not only do many of the proposed policies require a significant upfront cost, they also require additional staff resources to formulate, develop and implement; these two factors alone have delayed the implementation of some of the recommendations set forth in the Unified Long-Term Care Budget Workgroup. On January 21, 2010 the Department of Aging hosted a Unified Long-Term Care Systems retreat to refocus and reenergize the group. The priorities and strategies that the workgroup plans to focus on going forward are: . Continuing consolidation of the budgeting process for long-term services and supports to achieve better balance in Ohio's LTSS system. Specifically, exploring strategies that will link the budgets for facility-based and home-based services and supports and exploring future options for funding; . Exploring changes that will improve the eligibility process and changing eligibility standards that will give consumers greater choice in service settings and will be more equitable across programs and services; . Completing Ohio's service array and improving the interconnections between service systems; . Integrating acute and long-term services and supports systems; . Improving the "front door" and increasing the effectiveness of Ohio's entry system for long-term services and supports; and. . Focusing on workforce development for direct service workers that will create greater opportunity and improve retention. In light of the current economic situation, the Department of Developmental Disabilities created a fiscal plan for their Home and Community-Based Waiver Services that includes the following recommendations: . Improve the developmental disability community.s ability to increase the number of individuals receiving some level of service; . Sharpen the effectiveness of current cost management features of the waivers, while affording healthy and safe choices for individuals and families; . Create additional waiver options to meet the varying and changing needs of many individuals and families, especially those still waiting for wavier-like services; . Reduce disparities in direct care wages across service settings; and . Provide systemic tools to help the system confront the certainty that the future will include significant economic constraints. The recommendations in this plan are the means for accomplishing these goals. As a result of fiscal challenges, including reductions in General Revenue Fund (GRF) and mental health block grant funding, the Department of Mental Health (ODMH) has begun to: . Prioritize core mental health services with safety and security being at the forefront; . Facilitate recovery and resiliency through peer support activities through local continuums of care; . Fiscal Officers are using the risk assessment model to monitor fiscal conditions of local mental health systems; and . The Forensic office will continue to work with the boards to assure that forensic monitoring is occurring, assuring the reports are accurate and up-to-date to identify any noticeable trends. In addition, in collaboration with the Department of Alcohol and Drug Addiction Services (ODADAS), ODMH is proceeding with the following as outlined in a March 2009 system sustainability plan: . Provide quality incentives to providers through implementation of a fee schedule; . Create a support structure that promotes accountability and fiscal planning; . Develop a framework for core services – treatment, prevention and recovery support – that allows consumers appropriate availability and quality; . Establish benefit packages to target resources to those most in need; . Expand use of technology for efficiency and transparency; and . Decrease administrative burdens and increase flexibility through deregulation. Also, both ODMH and ODADAS have applied for and received waivers on Maintenance of Effort requirements set by the federal government. This has allowed for continued federal funding even though state funding has been reduced. Other challenges that state agencies experience during these difficult economic times: . Limited human resources make normal implementation activities difficult, e.g. meetings, advocacy, and outreach; . Developing partnerships to leverage limited resources; . Working with local public housing authorities and local housing providers; . Lack of safe, decent and affordable housing and a limited amount of funding for housing; and . Decreased availability of Section 8 vouchers (tenant and housing based).