Empower and support people with disabilities and elders to live independly

a vIsIon For THe FuTure
by expanding,
strengthening, and integrating systems of community-based
long-term supports that are person-centered, high in quality and
provide optimal choice.
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I. suMMary
The Commonwealth of Massachusetts is establishing its community First
olmstead Plan pursuant to a Supreme Court decision compelling states
to create meaningful community living plans for people with disabilities
and elders. In keeping with the framework of Olmstead v. L.C. and the
Patrick Administration’s commitment to a “community fi rst” long-term care
policy, this plan embraces a vision of choice and opportunity that requires
the deliberate development of more accessible and eff ective long-term
supports in local communities. Thus, the Plan supports the Administration’s
commitment to shifting focus of long-term care fi nancing from institutions
to the community. Grounded in the 2002 People’s Plan and the extensive
home and community-based service developments that have occurred
through the eff orts of the Executive Offi ce of Health and Human Services
(EOHHS), the Plan has greatly benefi ted from the signifi cant input of a broad
array of internal and external stakeholders (see Appendix B).
Focusing on six critical goal areas, the Plan provides a roadmap for the
future of community-based support for elders and people with disabilities.
Strategic short-term objectives describe an eighteen-month course of action
for the Administration in crucial regulatory, fi scal and program development
arenas which will, of necessity, be contingent on the availability of re-aligned
as well as new public and private long-term support funding.
The public-private collaborations that have brought the Plan thus far will
be the cornerstone of future eff orts and hold the promise of new and
meaningful opportunities for the nearly 20% of Massachusetts residents who
are elder or disabled and want the opportunity to choose community fi rst.
4 The Community First Olmstead Plan
II. Background
What is an Olmstead Plan?
In 1999, the U.S. Supreme Court rendered a favorable decision in Olmstead
v. L.C, a case that challenged the state of Georgia’s efforts to institutionalize
people with mental disabilities. The Court ruled that the Americans with
Disabilities Act (ADA) required states to provide services in the most
integrated settings appropriate to the needs of individuals with disabilities;
additionally, the Court indicated that each state should develop an Olmstead
plan consistent with the decision. The 2001 federal New Freedom Initiative,
multiple subsequent directives and grant funding from the Centers for
Medicare and Medicaid Services, and extensive monitoring by the Office
of Civil Rights, the National Council on State Legislatures, the American
Association for Retired Persons, and others have supported and tracked the
development of Olmstead plans now underway in most states.
Why is an Olmstead Plan important to Massachusetts?
The elder and disabled populations in Massachusetts are growing. They are a
diverse group of individuals and many depend on state-supported programs.
With a broad array of home and community-based services, including case
management and housing supports, they may live in less restrictive, and
sometimes less expensive, community-based settings where many wish to
remain.
Approximately 1.64M (20%) of Massachusetts’ residents are elders or
people with disabilities; over 300,000 are enrolled in MassHealth, and
32,000 are in nursing facilities on an average day.
Of the 856,000 elders in Massachusetts, approximately 104,000
(12.1%) are enrolled in MassHealth.
Of the 785,000 persons with disabilities in Massachusetts,
approximately 210,000 (26.8%) are under age 65 and enrolled in
MassHealth.
The current federal long-term care financing system tends to favor
institutional over community care.
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Among the approximately 250,000 elder or disabled MassHealth
members living in the community, there is a desire for increased
access to community support services. Many more elders and
people with disabilities who are not enrolled in MassHealth also
desire increased access to home and community-based support.
MA is in the highest quartile of states for the number of nursing
home beds per population.
Employment opportunities, critical for supporting people with
disabilities in leading self-sufficient and independent lives, are limited
in MA as elsewhere.
People with disabilities in MA are almost three times as likely to be
unemployed as their non-disabled peers (American Community
Survey, 2006).
Access to affordable and accessible housing often functions as one of the
greatest challenges to individuals successfully leaving institutional care.
Lack of many community service options limits the ability of elders and
people with disabilities to choose community over institutional care.
How was the Plan developed?
At Governor Patrick’s request, an Olmstead Planning Committee was
convened in late Fall 2007. A large group of representatives including
provider, consumer, and advocacy organizations, as well as elders and
people with disabilities (see Appendix B), worked collaboratively with state
agency staff to develop the framework and implementation strategies for
the Administration’s Plan. The People’s Olmstead Plan, which was produced
by a group of consumer advocates in 2002, provided the starting point for
the discussions. Using the People’s Plan goals as a foundation, the Olmstead
Planning Committee reviewed prior and current EOHHS initiatives focused on
achieving Olmstead-related objectives and identified gaps in needed service
and policy development. The Committee articulated six over-arching goals
and focused on identifying short-term action steps that now form the basis of
an eighteen-month implementation plan (Appendix A).
6 The Community First Olmstead Plan
What are the Principles that underlie this Plan?
The primary principles that inform the Plan are the following:
People with disabilities and elders should have access to community
living opportunities and supports;
The principle of “community first” should shape state elder and
disability policy development and funding decisions;
A full range of long-term supports, including home and communitybased
care, housing, employment opportunities, as well as nursing
facility services are needed;
Choice, accessibility, quality, and person-centered planning should be
the goals in developing long-term supports;
Systems of community-based care and support must be strengthened,
expanded and integrated to ensure access and efficiency;
Public and private mechanisms of financing long-term care and support
must be expanded;
Long-term supports developed under this plan must address the
diversity of individuals with disabilities and elders in terms of race,
ethnicity, language, ability to communicate, sexual orientation, and
geography.
The Community First Olmstead Plan is a work in progress. Ongoing
community engagement will be critical to implementation, evaluation, and
revision as the Plan evolves to meet changing needs and resources.
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III. The Community First Olmstead Plan
The overarching purpose of the Massachusetts Olmstead Plan is to maximize
the extent to which elders and people with disabilities are able to live
successfully in their homes and communities. Six goals provide the framework
for achieving that vision:
1. Help individuals transition from institutional care.
2. Expand access to community-based long-term supports.
3. Improve the capacity and quality of community-based
long-term supports.
4. Expand access to affordable and accessible housing
and supports.
5. Promote employment of persons with disabilities and elders.
6. Promote awareness of long-term supports.
Detailed objectives and timeframes for each of the goal areas are included
in Appendix A. The rest of this section highlights the major objectives and
provides additional background for each goal area.
1. Help individuals transition from institutional care.
Objectives:
Expand existing and implement new mechanisms for identifying
individuals in institutions who wish to live in the community
Implement additional mechanisms for facilitating transition from
institutional settings
This goal reaches to the heart of the Olmstead decision and, thus, is a core
obligation of this Plan. Successfully identifying institutionalized individuals who
want to move back home or to other community settings can be challenging.
Aging Service Access Points, Independent Living Centers, EOHHS agency staff,
and other disability and elder related organizations currently work to engage
individuals in transition processes, but a more systematic approach is needed
to ensure greater success. Implementation of the Long-term Care Options
Counseling process, mandated under Chapter 211 of the Acts of 2006, and
initiation of the transition services components of the planned Community
First (CF) 1115 waiver, the Hutchinson settlement, and the alternative Rolland
8 The Community First Olmstead Plan
settlement will put in place capacity needed to facilitate successful movement
of institutionalized individuals to community settings. Ongoing assessment of
the effectiveness of transition interventions will provide a basis for continuous
quality improvement.
2. E xpand access to community-based long-term supports.
Ob jecti ves:
Improve access to necessary home and community-based services
including, but not limited to, case management, medication
management, behavioral health, caregiver supports, and assistive
technology for elders and persons with disabilities
Improve access to accessible transportation for elders and persons
with disabilities
Improve transition services for adolescents with disabilities who are
leaving the education system
Massachusetts’ public and private systems of long-term supports are unevenly
available to elders and people with disabilities. In the public arena, one of
the challenges to access is differing financial and clinical eligibility standards
that exist across programs and funding streams that particularly affect
persons as they age and/or their conditions change. In this goal area, the
focus will be on reviewing eligibility standards to implement ways to broaden
coverage as resources permit. Successfully launching the Community First
1115 Waiver is the major focal point of this goal during the initial Olmstead
Plan implementation period; 15,600 people will be enrolled by the end of
the eighteen-month timeframe. During this same period, EOHHS will also
begin to meet the obligations of the resolution of both Hutchinson v. Patrick
and Rolland. Over time, services developed in response to these cases will
reach hundreds of individuals currently residing in nursing homes. The state
will also explore the feasibility of expanded Medicaid community support
coverage options for other disabled and elder MassHealth members, such
as those permitted under the federal Deficit Reduction Act. Additionally, the
development of expanded private and public-private financing mechanisms
for long-term supports will be initiated.
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The implementation plan references several current program review processes
underway that will, when completed, yield solutions to other access challenges.
The Personal Care Attendant Improvement Workgroup, for example, will
identify and implement effective ways to improve the MassHealth program’s
operations. The EOHHS Turning 22 Initiative is working to guide changes in
planning and supports for young adults with disabilities who are turning 22 and
aging out of educational services. The absence of a clear “agency of tie” for many
of these young people makes adult service planning challenging.
Even when community services exist, access is often complicated for both
elders and people with disabilities by the often limited availability of accessible
transportation options. Several EOHHS initiatives currently focused on
increasing transportation access will expand cross-secretariat coordination and
collaborative purchase mechanisms.
A core principle of the Olmstead Plan is choice, choice that is informed,
supported, and secure. Work within this goal arena will assure that expanded
consumer empowerment and decision-making is accompanied by
improvements in current guardianship regulatory and administrative practices.
3. Improve the capacity and quality of community-based long-term supports.
Ob jecti ves:
Expand and sustain a high-quality workforce in the community
Increase availability and diversity of residential support options
Improve financing for community-based long-term supports
Incorporate self-direction in the long-term supports system
Implement system-wide quality improvement processes in the existing
and future long-term support delivery systems
The success of the state’s efforts to effectively assist individuals in returning
to live safely in the community relies on enhancing access to high quality
community-based services. This requires an adequate workforce, funding
for a broad mix of services, flexible choices that respond to diverse needs
and preferences, including culture and communication, and a system that is
responsive to changing individual needs