During the last biennium, Texas has made some progress to improve services and supports for individuals with intellectual and developmental disabilities. Specific policy and program improvements have been made in the areas of transitioning from institutional settings to community living, accessing home and community-based waiver supports, and Medicaid system reform. While progress has been made, there are still significant areas for improvement.
Transition from State Schools to Community Living
Home and Community-based Waiver Expansion
The 79th Texas Legislature (2005) provided funds for the 2006-07 biennium making it possible to serve an additional 9,360 individuals through the Medicaid waiver programs as well as through non-Medicaid funded services.
Similarly, the 80th Texas Legislature (2007) appropriated $71.5 million in General Revenue and $167.3 million in All Funds for expansion of Medicaid waiver and non-Medicaid community services. The additional funding allowed DADS to serve 8,902 more individuals according to the following breakdown:[table “24” not found /]
DADS also began to refer more individuals living in state schools/centers to community settings. While these funds have provided needed services to thousands of individuals, Texas is not moving strategically or quickly enough to meet the current and future demand for services.
Community Living Options Information Process
Senate Bill 27 passed by the 80th Texas Legislature (2007) has changed the way that residents of state schools and state centers and their Legally Authorized Representatives (LARs) are informed about options for living in the community. The new Community Living Options Information Process (CLOIP) aims to minimize any conflicts of interest between the state school/center, resident, LAR or local Mental Retardation Authority (MRA) in helping residents and LARs understand community options. Local MRAs now have the responsibility for providing this information for adults, 22 or older, who live in a state school/center in the MRA’s service area. Despite these efforts, many residents do not get the information about the community living options they choose.
Institution to Community Relocation Efforts
As part of the state’s response to the Olmstead decision, several initiatives have been undertaken to help people relocate from institutions to the community. In September 2001, Rider 28 was implemented, which has helped more than 12,030 Texans in nursing facilities transition back to the community to receive their long-term services and supports. Rider 28, also known as “Money Follows the Person” or “MFP” established a method-of-financing whereby an individual’s service dollars “follow” them when they move from an institution to the CBA waiver program. This allows nursing facility residents to return to the community without having to be placed on a community service interest list.
While the MFP financing mechanism has proven successful for individuals living in nursing facilities, it does not provide people living in state schools/centers and ICFs/MR with the same opportunity. During the 80th Texas Legislature (2007), funds were appropriated for 250 “Promoting Independence” HCS slots for people in state schools. These slots are available to state school residents who receive a referral to community. In addition, the 80th Legislature appropriated funds for 240 Promoting Independence HCS slots for individuals in large community ICFs. Rider 41 (General Appropriations Act, 80th Legislature, 2007) allows DADS to provide waiver services to an individual under the age of 22 moving from a nursing facility who does not qualify for a nursing facility waiver program (e.g. CBA), but does meet the eligibility requirements of another waiver program (e.g. HCS). Additionally, Rider 43 (General Appropriations Act, 80th Legislature, 2007) allows DADS to provide waiver services to 50 individuals under the age of 22 moving from a small or medium community ICF/MR. While these slots are critical in relocating individuals to the most integrated setting, individuals in ICFs/MR who wish to move to the community are limited by the relatively low number of slots made available to them.
Additionally, the Texas Health and Human Services Commission (HHSC) and the Texas Department of Aging and Disability Services (DADS) will receive approximately $17.9 million in new funding over the next five years, which will be paired with existing state and federal funding for a total of $143 million under the Federal MFP Demonstration Grant, awarded to Texas by the Centers for Medicare and Medicaid Services.
The agency will use the money to enhance the MFP initiative and expand efforts for persons with intellectual and developmental disabilities, and persons with behavioral health needs. Specifically, DADS will develop a pilot project to transition adults with behavioral health (mental health or substance abuse) needs from nursing facilities to the community. Up to 50 individuals will be served each year in the San Antonio area.
This demonstration project will also enable DADS to allow up to 400 individuals currently receiving ICF services to transition to HCS, but only if their provider decides to convert their program to provide HCS services. While this strategy is a notable step forward, it is inconsistent with the principle of self-direction, one of the core principles of Money Follows the Person.
While improvements have been made in informing residents of community options, the transition of individuals from facilities — particularly children — has been slow. Permanency planning efforts are designed to assure a permanent family living situation for children. Recent reports on permanency planning for children in Texas indicates there has been a small decrease over the past five years in the number of children/individuals under age 22 who receive residential services through DADS. Generally speaking, since 2002 there has been an increase in the number of individuals moving into smaller facilities with fewer children living in the larger facilities. Two exceptions are in the number of individuals under 22 who live in state schools, which has increased by 23 percent (up from 241 to 297), and the number of individuals under 22 who live in medium ICFs/MR; a 49 percent increase (up from 39 to 58). Overall, there has been a decrease from 1,508 in August 2002 to 1,434 on February 28, 2007; a total of only 74 children in five years.
Study on Intermediate Care Facilities
On January 16, 2008, the Speaker of the Texas House of Representatives, Tom Craddick (Midland), announced the creation of the House Select Committee on Services for Individuals Eligible for Intermediate Care Facility Services. The committee was charged to evaluate the state’s infrastructure for serving persons with cognitive disabilities and to make recommendations for new ways to improve the quality and availability of care in multiple settings. The committee focused on people who are eligible for services of intermediate care facilities including state schools. In addition to an investigatory role, the committee was charged to assess the risks to the health and well-being of persons eligible for state ICFs/MR services that are not being addressed by the state’s current system. The committee is directed to review the assessment process used in determining eligibility for ICF/MR services and to evaluate the state’s ability to comply with federal regulations regarding services and supports for individuals with cognitive and developmental disabilities.
Home and Community-based Services and Supports
Consumer Directed Services
The Consumer Directed Services (CDS) option was expanded and made available to individuals enrolled in the Home and Community-based Services (HCS) and Texas Home Living (TxHmL) waiver programs in 2008. The CDS option allows individuals or their legally authorized representative (LAR) to hire, train, supervise and fire the persons who provide their services. Financial management services, such as processing payroll and taxes, are provided by a CDS agency. Individuals enrolled in HCS may now self-direct their supported home living and respite services. Individuals enrolled in TxHmL now have the opportunity to self-direct some or all of their services. This expansion allows a greater number of individuals with developmental disabilities to self-direct their support services. People who prefer the traditional agency model continue to have that option to obtain services.
The CDS option was already available in programs such as Primary Home Care, Family Care (FC), Community Attendant Services (CAS), Community-Based Alternatives (CBA), Community Living Assistance and Support Services (CLASS), Deaf-Blind with Multiple Disabilities (DBMD), Medically Dependent Children Program (MDCP), and Consumer-Managed Personal Attendant Services (CMPAS). People in these programs can now use the CDS option to self-direct some waiver services such as nursing, physical therapy, occupational therapy, speech/hearing/language therapy, attendant services, and respite. However, CDS is not available for all waiver services in all programs.
Medicaid Waiver Expansion
The Department of Aging and Disability Services (DADS) expanded the Community Living Assistance and Support Services (CLASS) program statewide in 2008. The CLASS program is a Medicaid waiver that provides home and community-based services to adults and children with related conditions as a cost-effective alternative to placement in an Intermediate Care Facility. People with “related conditions” have a qualifying disability, other than mental retardation, which originated before age 22 and which affects their ability to function in daily life. CLASS was previously offered in only about half of the state’s counties. Unfortunately, the choice of providers remains limited in some areas.
Pilot Program for Children with Autism Spectrum Disorders
It is estimated that one of out every 200 children in public schools in Texas is diagnosed with autism[10. Fighting Autism (Accessed October 2008).]. In efforts to further expand supports for children, the Department of Assistive and Rehabilitative Services (DARS) has implemented a pilot program to serve Texas children with autism spectrum disorders. The $5 million initiative will expand services for an estimated 300 children 3 to 8 years of age.
Mental Health System Redesign
The 80th Texas Legislature (2007) allocated $82 million in new funds to redesign the community mental health crisis safety net to reduce the number of people who are admitted to emergency rooms, jails, and state hospitals. Changes include creating a 24-hour, seven-day-per-week telephone crisis service with trained staffers, creating local outreach teams that go to the consumer’s home, and mobile psychiatric emergency units that will travel to local hospitals as needed. This is part of a larger Mental Health Transformation project initiated in 2005. A 21-member Mental Health Transformation Working Group consisting of state leaders, agency officials, and mental health consumers provides strategic guidance and direction for mental health transformation.
State Medicaid System Improvements
The 80th Texas Legislature (2007) passed and the governor signed Senate Bill 10, which calls for improvements to the Texas Medicaid program by focusing on prevention and better planning to help Texans to live longer, healthier lives. Specifically, this program calls for a Health Opportunity Pool that would provide federal dollars to reimburse hospitals for uncompensated care, premium payments for employees who are Medicaid eligible but enroll in employer-sponsored insurance plans, an extension of Medicaid coverage for foster children to age 23 if they are attending college, and a tailored benefits package for populations such as children with special health-care needs.
Integrated Care Management
Individuals in 13 counties began receiving Medicaid services through the new Integrated Care Management (ICM) program in 2008. ICM combines regular health care, such as doctor visits, with long-term services and supports, such as in-home attendant care. Key components of the fee-based model include the use of service coordinators, consumer advocates, community groups and providers, in-home services, and electronic health records. ICM provides coverage primarily for people who receive Medicaid and Supplemental Security Income (SSI), and are age 21 or older, and those who receive services through the CBA waiver program. Children under the age of 21 who receive SSI may choose to participate in ICM or stay in traditional fee-for-services Medicaid. People who are in institutional settings (nursing homes) and people in waiver programs other than CBA are not eligible for the ICM program. Medicaid recipients who meet this criteria and live in Collin, Dallas, Denton, Ellis, Hood, Hunt, Johnson, Kaufman, Navarro, Parker, Rockwall, Tarrant and Wise counties are included in the program. Individuals with I/DD do not currently receive ICM services.
Access to Children’s Medicaid Services
The 80th Texas Legislature (2007) approved $150 million for strategic initiatives to expand children’s access to Medicaid services. Most of the funding is being used to increase payment rates for dentists, physicians, and specialists to encourage more health care providers to accept Medicaid patients. The state’s Medicaid program covers more than 2 million children — or one out of every three children in Texas. The Early Periodic Screening, Diagnosis and Treatment (EPSDT) service, known as the Texas Health Steps (THSteps) in this state, includes the Comprehensive Care Program and Medical Transportation Program for beneficiaries under the age of 21.
Medicaid Infrastructure and Competitive Employment Support
The Department of Assistive and Rehabilitative Services (DARS), in collaboration with the Health and Human Services Commission, has been awarded a four-year Medicaid Infrastructure Grant (MIG). The grant from the federal Centers for Medicare and Medicaid Services (CMS) will be used to develop the infrastructure for a comprehensive system of competitive employment support for persons with disabilities. The goals of the project are to increase enrollment in the statewide Medicaid Buy-In (MBI) program and expand the MBI program statewide to support its effectiveness as a work incentive. The Medicaid Buy-In program allows workers who have a disability to receive Medicaid by paying a monthly premium in order to maintain access to the same Medicaid services such as office visits, hospital stays, X-rays, vision services, hearing services and prescriptions. The project will also improve public and private employment resources for persons with disabilities, increase partner collaboration among those who provide employment resources (e.g., Vocational Rehabilitation (VR) and One-Stop Workforce Centers), and educate consumers about work incentives and workforce system services to enhance their use.