cil-net presents…

1CIL-NET, a project of ILRU – Independent Living Research Utilization1

CIL-NET Presents…CIL-NET Presents…

1

Implementing and Enforcing OlmsteadA National Onsite Training

The California IL Approach to Olmstead

May 11, 2011Atlanta, Georgia

Presenter:Laurel Mildred

California Foundation for Independent Living Centers (CFILC)


Who We AreWho We Are

• Based in our state capitol of Sacramento, the California Foundation for Independent Living Centers is a statewide, non-profit trade organization representing 24 Independent Living Centers.


CFILCCFILC

• The mission of the California Foundation for Independent Living Centers is to advocate for barrier-free access and equal opportunity for people with disabilities to participate in community life by increasing the capacity of Independent Living Centers to achieve their missions.

• The statewide approach has resulted in strengths in public policy, organizing and technological innovation.


TopicsTopics

I. CFILC’s Olmstead Project

II. Our 2010 “Olmstead Summit”

III. Key Policy Work

4


I. Our Olmstead ProjectI. Our Olmstead Project

Background

After receiving ILC community input, the State Independent Living Council and the California Department of Rehabilitation made Olmstead implementation a priority, and designed several grant opportunities intended to advance implementation using American Recovery and Reinvestment Act (ARRA) funds.

One of these projects emphasized public policy.


Funded Through ARRAFunded Through ARRA

• In 2009, CFILC applied for and was awarded the public policy grant from our state Department of Rehabilitation. It is a two-year project.

• Our proposal was to re-start a defunct Olmstead Coalition, and to bring policy and training resources to ILCs and other advocates in order to strengthen their capacity to move Olmstead forward.


Californians for OlmsteadCalifornians for Olmstead

We called our project

CALIFORNIANS FOR OLMSTEADCALIFORNIANS FOR OLMSTEAD..


Mission StatementMission Statement

• The mission of Californians for Olmstead is to work toward community inclusion of all people with disabilities in California through the implementation of the Olmstead decision. We do this by working with people with disabilities to secure public resources and quality support needed for people to live full and equal lives in the community.


Broad StrategiesBroad Strategies

• Coalition Building: The Project provides a context for ILCs to work with other organizations, such as aging, disease-specific, and poverty and civil rights advocates.

• Deepen Policy Focus: The Project has provided in-depth focus on key issues, and informs and supports the ILC “Systems Change Network” as well as Coalition partners.

• Coordination with Transition Services: The Project connects with ILC’s in their role as transition services providers, bringing their hands-on experience into policy advocacy.


Major Project ActivitiesMajor Project Activities

• Develop Communications Structure, Website, Facebook Page, Listserv

• Revitalize Olmstead Coalition• Hold Monthly Teleconference Meetings• Achieve Public Policy Outcomes (4-6

positive and 4-6 defensive)• Take Advocacy Action and Develop

Toolkits• Organize a Series of Trainings


• Lack of specificity and accountability in California’s Olmstead Plan.

• Lack of a “system” in the long term care system, characterized by fragmentation of services and funding, with implications for the individual consumers and the overall budgets for services.

• Policymakers’ acknowledgement of the effectiveness of the In Home Supportive Services (IHSS) program in reducing dependence on nursing home services, juxtaposed with policymakers reduction in funding for IHSS.

Our Initial Assessment of Our Initial Assessment of BarriersBarriers


• Small federally-funded pilot programs, but no overall commitment to expanding those programs to other areas or other populations.

• Huge increases in spending for nursing homes, whose funding is separate from home and community-based services.

• Lack of legislative knowledge and leadership on Olmstead and community integration, as compared to legislative mandates in other states.

Our Initial Assessment of Our Initial Assessment of Barriers, cont’d.Barriers, cont’d.


• Duplicative use of assessments for long term care users and lack of true care management for those who want it.

• Lack of affordable, accessible housing as a major barrier to community integration, with no coordinated effort to overcome this barrier.

Our Initial Assessment of Barriers, cont’d. 2


• California’s ever worsening budget problems have put advocates on constant defense over a period of years.

• Cuts have impacted all services in the community system of care, and taken together, the UCLA Center for Health Policy estimated that the proposals “turn back the clock 30 years” on California’s long-term care system. Some of these cuts have been defeated, others have become the new normal.

Situational Analysis: Situational Analysis: All Budget, All the TimeAll Budget, All the Time


• This year Governor Jerry Brown proposed, and the Legislature has adopted, $12.5 billion dollars in statewide program cuts (to all programs and services). Balancing our budget now requires $12.5 billion from extending current temporary taxes that are set to expire.

• The revenue piece has precipitated a large political battle.

• Without resolution, California faces an “All Cuts” budget of an additional $12.5 Billion in reductions.

And It’s Not Over YetAnd It’s Not Over Yet


• A key challenge of the Project has been to stay active and relevant on fighting devastating cuts while holding the space for a longer-term vision of system change.

• We tried to bring valuable budget resources to support advocacy, stay involved in the key long-term system change issues, and set careful priorities for issues to go into in more depth.

And It’s Not Over Yet, cont’d.And It’s Not Over Yet, cont’d.


• Foremost Consideration – Achieving Grant Deliverables

• Organizational Priorities – CFILC ED Coordinated Work with Systems Change Network and Other ILC Projects

• Expressed Concerns of ILC Directors• Expressed Concerns of Coalition Members• Project Manager’s Experience – Discretion

to Pursue Critical Policy Issues

How We Set Policy PrioritiesHow We Set Policy Priorities


These will be live, interactive, accessible webinars (Elluminate training platform)

1. Critical Issues in Olmstead Implementation Overview, Policy Framework and Review of Litigation

2. There's No Place Like HomeThe HUD HOME Investment Partnership Presents an Opportunity to Support Housing for People Transitioning From Institutions – with Steve Gold

Our Training SeriesOur Training Series


3. The Game-Changing Strategy Building an Effective System of Long-term Services

and Supports through Implementation of the Federal Affordable Care Act

4. Follow the Money Using Cost-Effectiveness in Advocacy for Long-term Services and Supports

5. Getting the Message Out Enhancing Advocacy Through Effective

Communication about Olmstead

Our Training Series, cont’d.Our Training Series, cont’d.


• Our final deliverable, due in September, is a blueprint for future action.

• This report will be posted on our website.

Final Project OutcomeFinal Project Outcome


• Our Major Year-One Project was to Convene Disability Community Leaders and Advocates from Around the State Around Issues of Olmstead Implementation

• We Planned, Collaborated and Shared Costs with our Protection and Advocacy Organization, Disability Rights California

II. California Olmstead SummitII. California Olmstead Summit


II. California Olmstead Summit, II. California Olmstead Summit, cont’d.cont’d.

• In September of 2010, 50 Key Leaders Gathered from Around the State to Hear a Keynote from the Department of Justice and Participate in the Summit.

• Day 1 Included 4 Policy Panels Featuring State and National Experts

• Day 2 Included a Training in Communications by Public Works; the DEMOS Center for the Public Sector


Overview PanelOverview Panel

• Reviewed budget cuts that had an Olmstead impact

• Assessment of political climate from a key legislative staff ally

• Overview of long-term care provisions of health care reform

• Academic research that would support removing the institutional bias of Medicaid


• Disability Rights California Reviewed Olmstead Litigation in California

• National Senior Citizens Law Center Reviewed National Medicaid Litigation

• The Bazelon Center for Mental Health Law Reviewed Critical National Olmstead Litigation

Legal Strategies PanelLegal Strategies Panel


• Review of Advocacy from 1999 to Now• Using Cost-Effectiveness Arguments in

Advocacy• Recommendations from the Author of: Long-

term Care Reform in California: Recommendations of the Home and Community-Based Long-term Care Report

http://www.hcbs.org/moreInfo.php/source/152/doc/2730/Home_and_Community-Based_Long-Term_Care:_Recommend

• Strategies for Moving a Reform Agenda

Panel on Long-term Care Panel on Long-term Care System ReformSystem Reform


• The Developmental Disability System (Our Lanterman Act)

• Mental Health Community-Based Models• An Effective County-Based System – San

Francisco• Expanding Successful Transition Services

in California (California Community Transitions – our Money Follows the Person program)

Successful Models PanelSuccessful Models Panel


• Research-based Communications Strategies for Conveying the Positive Role of Government in Addressing the Common Good

• Dominant Stories Shape Understanding (Hidden Reasoning)

• Critical Role of Master Narratives• Ways We Communicate that Make Things

Worse (For Example, Triggering Independence Rather than Interdependence, Conveying Stories of Desperation Rather than Aspiration)

What We Learned from DEMOS What We Learned from DEMOS Communications TrainingCommunications Training


• Successful Collaboration with DRC in Planning Event

• Developed Outstanding Content• Increased Relationships and Cross-Pollination

of Work• Excellent Participation and Excitement• Set Stage for Participation in Larger

Foundation-Sponsored Collaborative Working on Long-term Care Systems Reform (SCAN Foundation Initiative)

What We AchievedWhat We Achieved


What We Didn’tWhat We Didn’t

• Differences in Approaches Emerged • Participatory Workgroups Proved Difficult

to Sustain• Most Strategies Will Take a Longer-term

Effort than the Project Will Last


Olmstead Summit ResourcesOlmstead Summit Resources

• All PowerPoint Presentations and Handouts from the Summit, including the DEMOS Communications Training, May Be Found at Our Website:

www.californiansforolmstead.org under California Olmstead Summit


III. Key Policy WorkIII. Key Policy Work

Hopes and prayers, the general desire to do good without knowing how, seem to us frail

reeds on which to lean, though these are the bases on which many programs are begun.

-Pressman and Wildavsky, Implementation,

1984


ApproachesApproaches

• Articulate a Theoretical Framework• Utilize Policy Analysis• Promote Long-term Care Reform

Strategies Derived from Best Practices


• Social Justice and Consumer-Driven Orientation

• The Ecological Systems Model is an Overall Framework (Also described as Person-in-environment, Whole Person, or Bio-Psycho-Social-Spiritual Approach)

• Within this, the Strengths Perspective, Wellness Perspective, Family Theory, Culture Theory, Empowerment Theory, Recovery Model and Resilience Model are Useful

Policies Imply Theories: Policies Imply Theories: Articulate a Theoretical Articulate a Theoretical FrameworkFramework


Steps in Policy Analysis Steps in Policy Analysis

- -Eugene BardachEugene Bardach1) Define the Problem2) Assemble Some Evidence3) Describe Potential Options or

Interventions (Including the DO NOTHING Alternative)

4) Select Criteria that Will Define Success (Including Cost-effectiveness)


5) Project the Outcomes of Each Alternative (Including Consideration of Unintended Consequences)

6) Confront the Trade-offs (Sometimes Called a Cost-Benefit Analysis)

7) Decide Between Options8) Communicate Your Analysis in Simple

Terms

Steps in Policy Analysis Steps in Policy Analysis -Eugene Bardach, cont’d. -Eugene Bardach, cont’d.


Describing Potential Options: Describing Potential Options: Focus on Best PracticesFocus on Best Practices

• Characteristics of Effective State Long-Term Care Systems (Washington, Oregon, Vermont)

• Considering Best Practices in a State More Like California – Pennsylvania’s Successful Transition Services

• Characteristics of Effective County Long-Term Care Systems (San Francisco)


Effective State Long-term Care Effective State Long-term Care SystemsSystems

• Washington State began by defining a strong statement of Vision and Values that guided the development of the long-term care system.


Washington State VisionWashington State Vision

• Consumer choice should drive the long-term care system.

• Quality of life is as important as quality of care.

• No one service is more important than another – the most important service is the one the consumer wants and needs.


ValuesValues

• Persons with disabilities and their families are entitled to maximum feasible choice and participation in selecting care settings and providers.

• Persons with disabilities have the right to expect “quality of life,” personal dignity, maximum feasible independence, health and security.


• People with disabilities have a right to choose and direct a care plan involving “managed risk,” in exchange for the advantages of personal freedom.

• The array of public service options and individual consumer choices may be bounded by reasonable considerations of cost-effectiveness.

Values, cont’d.Values, cont’d.


Nine Critical Elements of the Nine Critical Elements of the Washington State Long-Term Care Washington State Long-Term Care SystemSystem1. A strong statement of mission and values

to guide system development2. A single organizational unit in state

government to plan, develop and operate the long-term care system

3. Single budget with flexibility and authority to spend on a varied array of long-term care services

4. Process for assuring quality oversight throughout the system


5. Strong and organized stakeholders and advocates

6. A process for resource development that meets consumer demand

7. Fast, timely and standardized financial and functional eligibility that generates reliable data

8. Care coordination system with capacity to provide assistance and oversight for consumers

9. Fair rate setting and contracting process for providers

Nine Critical Elements of the Washington Nine Critical Elements of the Washington State Long-Term Care System, cont’d.State Long-Term Care System, cont’d.


Recognizing Pillars To Build Recognizing Pillars To Build UponUpon• A Comparison of Core Elements in 3

States with Effective Long-term Care Systems: – Washington – Oregon– Vermont


Core Element Washington Oregon Vermont

Vision, Values Consistent w/Consumer Choice

YES YES YES

Single Org. Unit in State Government

YES YES YES

Single Budget w/Flexibility to Spend on Array of Serv.

YES YES YES

Quality Assurance Process YES YES YES

Strong, Organized Stakeholders & Advocates

YES YES YES

Sustainable Resources to Meet Consumer Demand (Efficiencies + Tax Rev)

YES, although proving weak in recession

NO – ONLY EFFICIENCIES --Reason for Current Erosion of System

NO - ONLY EFFICIENCIES – Utilized Homecare Tax – Erosion

Fast, Timely & Std Financial, Functional Eligibility

YES YES NO – Small state, do not have much problem w/this

Care Coordination System w/Effective Transitions

YES YES YES

Fair Rate Setting and Contracting Process

YES YES YES

Comparison of Core ElementsComparison of Core Elements


Effective Practices from States Effective Practices from States that are More Like Californiathat are More Like California

• Pennsylvania is a leading state in transitioning people from nursing homes. – It is more like California in that it has a strong

county-based system.


Targeted initiativesTargeted initiatives

Pennsylvania’s MFP Transition Program

• In 3 ½ years, PA transitioned 1,600 persons from nursing homes. Scaled to CA, that would be 4,600 persons per year.

• They estimate their savings to exceed over $200 million in nursing home expenditures.

• Roughly 1/3 of all transitions do not require state funded services following transition.


How?How?

• Funding: They started with a Money Follows the Person Grant, and added General Fund dollars. In 2008 they invested $10 million, in 2009 $14 million. – They use the general fund dollars to provide

the most flexible program aspects. They also have a line item in each state waiver to support transition.


How? cont’d.How? cont’d.

• Reimbursement Structure: They have 80 transition providers and pay them both for time spent w/consumers as well as for benchmarks (30,90,180, 270 and 365 days living in the community).

• Housing: Intense collaboration at Cabinet level between LTC and state Housing Finance Agency. Regional housing staff co-located in transition agencies. Preferences for people transitioning, rental assistance, and renter’s training programs.


Characteristics of Effective Characteristics of Effective County County Long-Term Care SystemsLong-Term Care SystemsUtilized in San Francisco, Informing in Sonoma

and San Diego

• Consumer-driven• Single Point of Entry (allows quality

assurance)• Comprehensive Package of Services that are

Tailored to the Individual and Can Change with His or Her Needs

• Seamless Transitions Between Care Settings


• Package Designed on Assessment, with Consumer Choice

• Funding for Services• Array of Services• Clear Lines of Responsibility and Oversight• Flexibility to Make Changes

Characteristics of Effective Characteristics of Effective County County Long-Term Care Systems, Long-Term Care Systems, cont’d.cont’d.


System Change: The Washington System Change: The Washington State State Long-Term Care Forecasting Long-Term Care Forecasting CommissionCommission• As a result of their effective long-term care

system, policymakers have confidence that spending these funds does actually save the state money.

• Solid assessment data allows the Commission to project total need for home and community-based services.

• The Governor and the Legislature agree without further ado to put the funding recommended by the Forecasting Commission into the budget for HCBS.


• Successful policies should take advantage of the effectiveness of statewide coordination as well as the efficiencies of the local delivery system, and have clearly defined state and county roles.

• There must be careful planning for these roles to be delineated, integrated and implemented. This usually does not happen and it is critical to successful outcomes.

• Never underestimate the power struggle between state and county government.

System Change: The Washington System Change: The Washington State State Long-Term Care Forecasting Long-Term Care Forecasting Commission, cont’d.Commission, cont’d.


System Change Opportunities In System Change Opportunities In Federal Healthcare ReformFederal Healthcare Reform

• In addition to expansion of health insurance coverage, created a long-term care framework

• CLASS Act – Long-term care insurance, no exclusion for pre-existing conditions, 5 year vesting period, $50 per day cash benefit to purchase services and supports

• Community First Choice – increases Federal share of community-based attendant services


System Change Opportunities In System Change Opportunities In Federal Healthcare Reform, Federal Healthcare Reform, cont’d.cont’d.• Home and Community-Based Services

State Plan Option• Expands and extends Money Follows the

Person demonstration projects• Extends spousal impoverishment

protections• Funding of Aging and Disability Resource

Centers• Care Transitions Program• Support for the Direct Care Workforce


Draft California LTSS System Draft California LTSS System Principles-Principles-As Proposed, Not Yet AdoptedAs Proposed, Not Yet AdoptedMission Statement• The California Collaborative advocates for the

dignity, care, maximum independence, and the physical, mental and economic well-being of Californians who experience disabilities, functional impairments, and chronic conditions. The Collaborative supports policies that prevent people from becoming impoverished, as well as a system of high-quality, cost-effective long-term services and supports that strengthen the person, his or her family, and caregivers.


Definition: Long-Term Services and Supports

• Long-term services and supports refer to a wide range of personal, medical and social/financial assistance needed by persons with functional limitations over an extended time. The services may be publicly or privately financed, delivered in a wide range of settings, and may change as the needs of the individual who uses the services change.

Draft California LTSS System Draft California LTSS System Principles-Principles-As Proposed, Not Yet Adopted, As Proposed, Not Yet Adopted, cont’d.cont’d.


Statement of PrinciplesStatement of PrinciplesThe Collaborative Endorses a System of Long-Term

Services and Supports Based on the Following Ten Principles:

1. Dignity: The services are grounded in respect for the person who uses them.

2. Choice: The services are driven by the preferences of the people who use them and access to all types of services is provided on an equal footing.

3. Flexibility: The services are comprehensive and flexible enough to meet changing needs and incorporate new modes of service and supports.

4. Quality: The services system values and rewards high-quality care.

5. Legality: The services are consistent with the legal rights of individuals who use them.


6. Cultural Competence: The services are appropriate and responsive to the needs of underserved populations.

7. Accessibility: The services are easy to locate and use and are physically and programmatically accessible.

8. Affordability: The services are cost-effective for the person and the system.

9. Inclusive: The services recognize and support high-quality paid and unpaid caregivers.

10.Independence: The services support maximum independence and quality of life.

Statement of Principles, cont’d.Statement of Principles, cont’d.


ConclusionConclusion

Community-Based Organizations Community-Based Organizations have to become the key engine have to become the key engine

for policy development. We must for policy development. We must increase our policymaking increase our policymaking

capacity to meet this challenge.capacity to meet this challenge.


Thank YouThank You

Laurel Mildred, MSWOlmstead Advocacy DirectorCalifornia Foundation for Independent Living

Centers1234 H Street, Suite 100Sacramento, CA 95814(916) 325-1690 voice(916) 325-1695 [email protected]

www.californiansforolmstead.org


CIL-NET AttributionCIL-NET Attribution

Support for development of this training was provided by the U.S. Department of Education, Rehabilitation Services Administration under grant number H132B070002-10. No official endorsement of the Department of Education should be inferred. Permission is granted for duplication of any portion of this PowerPoint presentation, providing that the following credit is given to the project: Developed as part of the CIL-NET, a project of the IL NET, an ILRU/NCIL/APRIL National Training and Technical Assistance Program.

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