Texas: Self-determination with Consumer Directed Services Marc S. Gold

Texas Department of Aging and Disability Services

October 5, 2010

National Academy for State Health PolicyReforming State Long-Term Services and Supports through Participant Direction

Consumer Directed Services (CDS) History 1997: House Bill 2084: pilot model of participant direction

1999: Senate Bill 1586; expand CDS option to Medicaid programs and established a CDS stakeholder workgroup 2001: CDS added to the Medicaid waivers

2004: Consolidation of Human Services

2010: CDS option in all waivers, state plan and managed care programs

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Long Term Services & Supports Program Waivers:

Older and Physical Disabilities Community-based Alternatives Medically Dependent Children Program STAR+ (managed care)

Intellectual and Developmental Disabilities

Home and Community-based Services Deaf-Blind Multiple Disabilities Community Living Assistance and Support Services Texas Home Living

State Plan Programs: Attendant Services Primary Home Care Community Attendant Services (b) attendant services

3Gold

What is Texas CDS? Not “cash and counseling” Mechanism to control hiring of selected direct service workers and licensed staff Service budget determined by agency staff Limited budget flexibility: determine pay rate within service rate set by state

Texas CDS is not: Cash option Service provision by legally liable adults (spouse/parent) “Individual goods and services”

4Gold

Texas 2010

All individuals, across disabilities and regardless of age have the option to use CDS

Statutory Authority

1915 (c) waivers 1915 (b) waivers (managed care) 1915 (j) state plan amendment (DRA 2005) TX: attendant programs No screening tool: self-determination

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Available Services through CDS

All programs: Personal assistance services; habilitation and respite

Selected waivers: Nursing and physical/occupational/speech therapies

Texas Home Living: All services

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Support Services to CDS Model

Financial Management Services (FMS)

payroll, deposit taxes and file tax reports $202/month in waiver program $110/month in attendant programs

Support Consultation

Assistance and training: coaching the individual how to interview/hire $15.37/hour (from overall budget)

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Getting the Word Out

Case managers or service coordinators provide information about the CDS option at program enrollment and annually upon service review

Information includes an overview of the CDS option, employer responsibilities, FMS provider responsibilities as well as benefits and risks of using the CDS option

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Individual Responsibilities

Serve as employer

Recruit and hire services provider

Determine the work schedule

Determine the wage rates and benefits

Provide initial and ongoing training

Approve services provider timesheets

Handle conflicts

If necessary, terminate provider9Gold

Budget and Spending Flexibility Budget based on approved service plan

Any budget change must be proceeded by a service plan change

Wages determined within the rate established by the state

Budget allows employers to purchase employer-related supports: advertising costs, fax machine for sending time sheets, background checks and training for attendants (not individual goods/services)

90% of budget must be allocated to service provider pay and benefits

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Utilization: 2008-2010

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

Total Number of CDS Users In Texas by Quarter

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Factors in Increase Usage

Addition of CDS to waiver program (HCS; MDCP)

Expansion of managed care to urban areas within Texas

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Population Differences

49% of participants with related conditions in CLASS waiver program

3% of participants with intellectual or developmental disabilities in HCS waiver

Less than 1% participants with physical disabilities and those who are aging in CBA

33% of parents of children with special medical needs MDCP waiver program

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Fee-for-Services vs. Managed Care

Less than 1 percent in fee-for-service Less than 1 percent in fee-for-service programs programs for individuals who are older or with physical disabilities

Three percent for same population in managed care

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Factors Impacting Usage

Elderly too ill to manage self-direction Lack of informal support to help with self- direction

Independent case managers versus agency case managers

Conflict of interest when case management provided by program provider

15Gold

Quality Assurance/Improvement

Data collected from the: Personal Experience Survey National Core Indicators

Those who use CDS reported they: required less medical attention required less support to prevent disruptive behavior felt safer in their homes were more satisfied with their lives felt less lonely

16Gold

Cost Effectiveness Studies

4 studies, however mixed results with inconclusive data

Trend data indicate:

Utilization of services increased with CDS Few hospitalizations and return to nursing facility

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Strengths/Considerations Strengths

Available to all individuals served by Texas’ long-term services system Operates under a single set of administrative rules; consistency

Considerations Ties CDS to specific waiver and rule requirements such as service plan developments/provider requirements, case management or service coordination Limits budget flexibility

18Gold

Workgroup Recommendations Develop and implement outreach activities across TX to increase awareness and understanding of the benefits of the CDS

Establish a certification process for CDS Agencies (CDSAs) to improve quality of services and ensure cost-effective oversight

Make workers’ compensation insurance affordable for workers

Create a budget neutral, cross disability, self-determination pilot waiver in at least one rural and one urban site

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Future Considerations

Service Responsibility Option Self-determination Waiver Addition of individual goods and services Require certification Regional “supra” contract role Increase responsibilities of support advisors

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Contact InformationMarc S. GoldDirector, Promoting Independence Initiative512.438.2260marc.gold@dads.state.tx.uswww.dads.state.tx.us/business/pi/index.html

Elizabeth Jones, Ph.D., CDS Specialist512.438.4855elizabeth.jones@dads.state.tx.us 21Gold

Websites

CDS Option:http://www.dads.state.tx.us/providers/CDS/index.cfm

TX Administrative Code: Title 40, Part 1, Chapter 41:http://www.dads.state.tx.us/providers.CDS/Ch41CDSJan2009.pdf.

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