Ohio Access Report 2004 -- Section II: Progress Report, 2001-2003

The Administration has embraced the Olmstead decision and is actually listening to us. And I mean listening. (M.B.)

The original Ohio Access report, issued in February 2001, contained recommendations to improve Ohio's long-term services and supports for people with disabilities. The recommendations were designed to support three guiding principles:

Increase community capacity;
Prioritize resources; and
Assure quality and accountability.

This section summarizes the impact of the original Ohio Access report. It documents the progress made under each priority between February 2001 and December 2003.

Increase Community Capacity

Ohio Access clearly demonstrates that publicly financed delivery systems must respond to individuals' preferences about where they receive services and supports. Most people with a disability prefer to live at home for as long as possible, and consider facility-based services only as a last resort. Ohio Access respects an individual's dignity and right to make this choice — and responds by creating more home and community based services (HCBS) and supports to meet the needs of people with disabilities.

Expanded Home and Community Based Medicaid Waiver Programs
Ohio relies on Medicaid home and community based waiver programs to provide community alternatives for people with disabilities who otherwise face institutionalization. Ohio Access recommended serving more people through Medicaid waivers, as the chart below illustrates. As of June 2003, 44,286 Ohioans were being served via home and community based waivers. This represents a 19 percent increase since the original Ohio Access report was published in February 2001 and a 30 percent increase since Governor Taft took office in January 1999.

Ohio's commitment to expand home and community based Medicaid waiver programs encompasses multiple service delivery systems. Significant progress has been made over the past three years (SFY 2001-2003) to expand all of Ohio's existing waiver programs.

PASSPORT — 26,605 Ohioans age 60 and over who otherwise would be eligible for Medicaid reimbursement in a nursing facility are at home today or in a community setting with support from ODA's PASSPORT program. The program has grown 17 percent over the past three years. There are no waiting lists, and future funding is expected to keep pace with increasing demand.
Home Care and Transitions — 7,718 Ohioans under age 60 with disabilities or individuals who are medically fragile receive services through the ODJFS Ohio Home Care or Transitions Waiver programs. Home Care waiver services include home delivered meals, assistive living devices, out-of-home respite care, and adult day health services. A number of former Home Care consumers are now served on other, more appropriate waivers. Last year, 2,338 people moved to the new Transitions Waiver for people with an ICF/MR level of care, and 41 people moved to existing waiver programs, like Individual Options. Home Care now serves 5,380 people with no waiting list.
Individual Options and Residential Facilities — 9,843 Ohioans with mental retardation or developmental disabilities receive services through the Individual Options (IO) waiver or the Residential Facilities Waiver (RFW) programs. MR/DD waiver programs have grown 76 percent since 2001, primarily as a result of MR/DD redesign (described below). However, despite the tremendous growth in these programs, services do not meet demand, and counties manage waiting lists for these programs.
PACE — More than 480 Ohioans age 65 and older who are either "dually eligible" for Medicare and Medicaid or Medicaid eligible only receive comprehensive services through a Program of All-Inclusive Care for the Elderly (PACE). Ohio currently has two PACE Program sites in Cincinnati and Cleveland. Each site is authorized to serve up to 240 participants. ODJFS recently requested approval from the federal Center for Medicare and Medicaid Services (CMS) to expand each site to 290 participants, with a further commitment to expand to 440 participants.

Created (or Proposed) New Home and Community Medicaid Waiver Programs
Ohio and most states want to be able to expand home and community based services without having to request federal permission to "waive" Medicaid's institutional entitlement. However, until Congress reforms Medicaid to give states more flexibility to design home and community based programs, Ohio will continue to rely on existing Medicaid waiver options to create new home and community based alternatives to institutional care.

Success Project — ODJFS created a pilot program in the SFY 2002-2003 budget (it was continued in the SFY 2004-2005 budget) to assist up to 250 nursing home residents return to community living if they desire. Some people are medically able to leave facility-based care but simply cannot afford the one-time costs associated with moving back into a community setting (modifications to their home, first months rent, etc.). Soon, the Success Project will provide services through Medicaid and will provide one-time financial assistance to cover relocation costs.
Choices — ODA created the Choices Medicaid waiver program to give 200 PASSPORT consumers in central Ohio more direct control over their choice in service providers. ODA will use Choices to test how best to incorporate and promote consumer directed care for older persons in PASSPORT and other settings.
Level I — ODMR/DD developed a new Level I Medicaid waiver program to provide opportunities for 6,000 individuals to remain in a home or community setting over the next three years.
ICF/MR Conversion — ODJFS and ODMR/DD proposed removing intermediate care facility for the mentally retarded (ICF/MR) services from the state's Medicaid plan (thus eliminating the institutional entitlement) and replacing those services with a new waiver. At a minimum, the same number of people would have been served, but individuals would have been able to choose where they receive those services. Governor Taft included this proposal in his SFY 2004-2005 budget, but it was not adopted by the General Assembly. This proposal or a similar one will be offered by the Administration during the SFY 2006-2007 budget process.
Assisted Living — Assisted Living is a popular choice among Ohioans who pay for their own care, but it is not currently available in Ohio through publicly-funded programs like Medicaid. Governor Taft's SFY 2004-2005 executive budget proposed creating a new Medicaid waiver for assisted living. Eligibility for the new waiver was to be limited to PASSPORT consumers who would otherwise have to move to a nursing facility because their need for services had become greater than their current environment could support, or seniors residing in nursing facilities who desire to live in a different setting and would be able to do so with a PASSPORT service package. Because the new waiver was designed to serve people already served by Medicaid, it would have required no new resources. Unfortunately, assisted living was eliminated by the General Assembly during its deliberations on the budget.

Chaired President Bush's New Freedom Commission on Mental Health
President Bush appointed ODMH Director Mike Hogan to Chair the New Freedom Commission on Mental Health. The President charged the Commission to study the mental health service delivery system and to make recommendations that would enable adults with serious mental illnesses and children with serious emotional disturbances to live, work, learn, and participate fully in their communities. The Commission reported that recovery from mental illness is now a real possibility, but that for too many Americans the services and supports they need are fragmented, disconnected and often inadequate. The Commission proposed transforming the nation's approach to mental health care to support recovery, and established six goals for this purpose: Americans understand that mental health is fundamental to overall health; mental health care is consumer and family driven; disparities in mental health services are eliminated; early mental health screening, assessment, and referral to services are common practice; excellent mental health care is delivered and research is accelerated; and technology is used to access mental health information. The Commission's final report is available at www.MentalHealthCommission.gov.

Prioritize Resources

Ohio Access is realistic about balancing priorities within the limited resources of families, community organizations and government. Government agencies need to determine where resources are achievable and can make the most difference. An important part of this process involves seeking cost efficiencies and appropriateness of care, particularly in institutions, thereby making more dollars available where Ohioans prefer to live — in their own homes and communities.

Slowed the Rate of Growth in Spending on Nursing Facilities
Public spending on nursing facilities continues to increase despite a declining demand for nursing facility services. Over the past eight years, Medicaid spending on nursing facilities increased 61 percent while the number of people in nursing facilities declined seven percent. Governor Taft recommended realigning nursing facility spending to match demand in his SFY 2000-2001 and SFY 2002-2003 budgets, but the General Assembly did not adopt these reforms. Governor Taft again proposed reimbursement changes in his SFY 2004-2005 budget and, given tremendous fiscal constraints, the General Assembly agreed to slow the rate of growth in public spending for nursing facilities to 3.2 percent in SFY 2004 (compared to a 7.7 percent increase that otherwise would have occurred per statute) and 1.0 percent in SFY 2005 (compared to 4.7 percent). As a result, the Ohio Medicaid program will spend approximately $191 million more on nursing facilities over the SFY 2004-2005 biennium — but that is $358 million less than Medicaid would have spent without this legislative intervention.

Completed a Fundamental Redesign of the MR/DD System
The original Ohio Access report and Governor Taft's SFY 2002-2003 budget called for a fundamental redesign of the state's services and supports for people with mental retardation and developmental disabilities. Every decision in redesign is based on the principle of consumer self-determination — the idea that individuals and their families are in the best position to make critical decisions about what constitutes quality of life. The basic policy changes of redesign are complete, but details will continue to be implemented for years. Some of the tremendous accomplishments of the past three years are listed below.

Refinanced existing county resources using Medicaid to draw down more than $100 million in new federal funds annually.
Increased the number of MR/DD home and community based Medicaid waivers (IO and RFW) by 76 percent over the past three years.
Developed a new Level I Medicaid waiver program to provide opportunities for 6,000 additional individuals over the next three years to enable them to stay in a home or community setting.
Provided $14 million in state general revenue funds (GRF) for tax-poor counties to "jump start" Medicaid refinancing.
Aligned funds from state ($9.85 million), county ($11 million), and federal ($30 million) sources to increase rates for service providers to recruit and train direct care workers.
Proposed removing ICF/MR services from the state's Medicaid plan (thus eliminating the institutional entitlement) and replacing those services with a new ICF/MR waiver.
Substantially increased local investments in health and safety for consumers.
Rewrote 53 state rules to strengthen consumer control. One example increased individuals' flexibility to self-administer their prescription medication.
Supported the recommendations of an Executive Branch Committee that includes representatives of families, county boards, providers, and state agencies to coordinate the redesign effort.

Downsized MR/DD Developmental Centers
ODMR/DD is committed to self-determination strategies for residents in developmental centers who want to leave the institution and live in a community setting. Over the past four decades, the number of residents in developmental centers decreased significantly from more than 10,000 people in 1963 to less than 2,000 people today. Over the past three years, the number of residents in developmental centers decreased 10 percent. Based on this trend, and in comparison to other states (Ohio has more state-run MR/DD institutions than all but one other state), ODMR/DD acted to close two of the state's twelve developmental centers.

Increased Medicaid Administrative Efficiencies
Ohio's Medicaid program is a primary source of funding for long-term services and supports in multiple state agencies. Six state departments assist ODJFS in the administration of Ohio's $9 billion Medicaid program. ODJFS is working to improve Medicaid administrative efficiencies, and some recent examples are listed below.

Restructured Office of Ohio Health Plans (Medicaid) to support Ohio Access activities. A new Bureau of Community Access provides assistance to other state agencies involved in Medicaid and monitors each agency's compliance with federal regulations.
Implemented a Medicaid Decision Support System to increase Medicaid's ability to manage costs, improve program decision-making, and improve federal reporting.
Modified state rules for Pre-Admission Screening and Resident Reviews (PASRR) to be clearer about responsibilities of nursing facilities and state agencies.
Obtained federal approval to expedite the settlement of an outstanding backlog of audits, which will permit settlement payments to Community Alternative Funding System (CAFS) providers in the MR/DD system.

Created a Medicaid Business Plan for Behavioral Healthcare
ODMH and ODADAS initiated, with ODJFS support, the development of a Medicaid business plan for behavioral healthcare to ensure that federal Medicaid fundamentals are applied consistently and on a statewide basis. Areas of focus include payment rates (fixed fee), reimbursement methodology, utilization review, and quality/performance requirements.

Used Federal Grants to Improve Access to Needed Services
Ohio received seven federal grants worth $3.5 million to manage Ohio Access activities. The grants were awarded by the federal Centers for Medicare and Medicaid Services (CMS) as an incentive for states to adopt policies and programs consistent with President Bush's New Freedom Initiative. Ohio was well prepared to win these grants, because the New Freedom Commission initiative is based on the same principles as Ohio Access (both are related to the Olmstead case.) ODA manages a Real Choice Systems Change Steering Committee to coordinate the grants described below. The Steering Committee includes representatives from each department that received grants, project managers and two representatives from the consumer-led Ohio Olmstead Task Force

ODJFS received a $50,000 Real Choice Systems Change "Starter" grant to plan for future Real Choice Systems Change activities. These funds were used to involve the Ohio Olmstead Task Force in subsequent grant design and implementation.
ODJFS received a $500,000 Medicaid Infrastructure grant to explore ways through Medicaid to support individuals who seek to obtain or retain employment.
ODJFS received a $600,000 Nursing Facility Transitions grant to secure a vendor to design, implement, and evaluate the Ohio Access Success Project, which provides Medicaid-eligible nursing facility residents with one-time financial assistance of up to $2,000 to relocate to community settings.
ODJFS received a $1.385 million grant to create a one-stop, on-line resource about services for people with disabilities. ODJFS contracted with ODA to create the site, which will be called No Wrong Door Ohio. The grant also supports the ongoing work of the Ohio Olmstead Task Force and a housing coordination position at ODJFS.
ODMR/DD received a $500,000 Independence Plus grant to develop a new home and community based waiver for people who want to exert greater control over their lives.
ODMR/DD received a $500,000 Quality Assurance grant to design and implement a quality information management system that will develop computerized tools to facilitate the collection, organization, analysis of data, and provide valuable information to all systems users about the needs of individuals and support agencies.
ODA received a $75,000 grant to study the feasibility of adding adult respite services to PASSPORT.

In addition to the CMS grants, ODADAS received a much larger $9 million, three-year federal State Incentive Grant from the Substance Abuse and Mental Health Services Administration to implement a comprehensive substance abuse prevention strategy. Most of the grant ($2.55 million annually) will go directly to 20 county ADAMHS/ADAS boards to support evidence-based prevention planning processes and programs.

Assure Quality and Accountability

Ohio Access sets a clear expectation that all publicly financed service delivery systems must assure quality and fiscal accountability throughout the system. Responsibility must be clearly defined throughout the system in order to ensure continuous quality improvement, consumer health and safety, and compliance with state and federal program requirements.

Created a Long-Term Care Consumer Guide
ODA created a comprehensive consumer guide to long-term care facilities at the direction of the General Assembly and with assistance from providers and consumers. The Long-Term Care Consumer Guide provides web-based information about nursing homes, including the results of ODH inspections, national quality indicators, and consumer satisfaction surveys. See: www.ltcohio.org

Conducted an Alcohol and Drug Addiction Services Shareholders' Process
Governor Taft initiated an Alcohol and Drug Addiction Shareholders process to create a shared vision for Ohio's system of alcohol and drug addiction services, provide input about how to align the state's resources toward achieving the vision, and recommend short-term changes to improve the system. The Shareholders' process concluded with the department's implementation of regulatory relief and improved processes to engage county boards, service providers, and individuals served by the system.

Implemented the Technical Assistance Program for Nursing Facilities
Facilities that are not performing well after being surveyed by the Ohio Department of Health can work with ODH staff to improve outcomes for their patients using proven curricula.

Took Steps to Address the Healthcare Workforce Shortage
Ohio Access recognized that for people with disabilities to have meaningful choices of services and supports, the shortage of health care workers needed to be addressed. This is difficult to do - workforce shortage issues are linked to overall employment and economic conditions inOhio — but several important steps were taken.

Ohio Health Care Workforce Shortage Task Force — ODH convened a task force to review health care workforce shortage issues related to licensing standards, scopes of practice, technology to alleviate workload, recruitment and retention, and education. See: http://www.odh.state.oh.us/ODHPrograms/HCFORCE/finalreport.pdf.
Ohio Health Care Workforce Advisory Council — ODA coordinates a Health Care Workforce Advisory Council through the Governor's Workforce Policy Board. The Council brings together consumers, providers, and state agencies to develop strategies to address critical shortages of healthcare workers. Additional information is available at: www.goldenbuckeye.com/wfadvisory.html.
Regulatory Relief — ODH initiated several changes in state rules to address workforce shortage issues, including allowing nursing facilities to use feeding assistants rather than nurses to help residents eat and drink, and broadening the work experience that is acceptable for nurse aides to remain on the State Nurse Aide Registry.

Implemented a Behavioral Health Quality Agenda
Ohio's behavioral health system leads the nation in assessing outcomes and using evidence-based services and supports. Over the past three years, the ODMH improved quality through its clinical quality agenda, regulatory relief and by addressing funding shortfalls that threatened access to acute hospital care.

Clinical Quality Agenda — ODMH used data and quality improvement practices throughout the system to improve outcomes for consumers. The department created a statewide network to promote recovery, Centers of Excellence to promote evidence based practices, a consumer outcomes measurement system, technical assistance to improve cultural competence, and training in data-based performance improvement.
Regulatory Relief — ODMH implemented new administrative rules to reduce barriers to provider efficiency while also increasing consumer protection. This strategy recognized national accreditation as meeting ODMH certification requirements, required that the majority of certified providers become nationally accredited before 2007, decreased duplicative documentation requirements (consistent with efforts to create a simplified quality- and recovery-oriented consumer record), and increased protection of vulnerable consumers by standardizing reports of significant incidents.
Hospital Care — ODMH led the nation in deinstitutionalizing behavioral health care services nearly two decades ago and reduced the number of state owned inpatient psychiatric beds by 60% between 1990 and 1998. Today, Ohio's public psychiatric hospitals are full and private inpatient capacity is being eroded. During SFY 2002 it became clear that state resources were not sufficient to cover ODMH's acute psychiatric hospital capacity. ODMH requested, and the Governor and General Assembly added, $23 million to avert hospital closures.

Achieved Quality Improvements Through MR/DD Redesign
ODMR/DD redesign enabled state and local investments in the infrastructure to assure health and safety and to improve outcomes for people with disabilities whenever possible. As new federal dollars flowed into the system, ODMR/DD:

Implemented an Abuser Registry to track people who are barred from employment as care providers for persons with MR/DD.
Implemented a Major Unusual Incident (MUI) tracking system that received national attention from CMS as a "Promising Practice."
Trained providers and administrators in every county to improve the MUI tracking.
Required county boards of MR/DD to employ Investigative Agents who are separate from any service provision to investigate major unusual incidents.
Completed statewide accreditation reviews for all county boards and quality assurance reviews for supported living and waiver providers.

Improved Programs to Identify and Treat Children with Disabilities
ODH coordinates several programs that are designed to identify children with disabilities as early as possible and connect them to appropriate services and supports.

Newborn Screening — ODH expanded the Newborn Metabolic Screening Program from five to 13 disorders. Parents have the option to screen their infant for an additional 16 disorders, for a total of 29 metabolic diseases. These are conditions that will cause developmental delay in infants if not treated immediately after birth.
Help Me Grow — Identified 25,645 infants and toddlers eligible for the Help Me Grow program. Help Me Grow provides developmental screening and service coordination and ongoing services for infants and toddlers at risk for or with developmental delays and disabilities. It is administered through county family and children first councils to assist families with young children to connect with community resources they may need to help their child develop appropriately. While ODH is the lead agency, county boards of MR/DD are significant providers of these types of services. See: www.ohiohelpmegrow.org.
Children with Medical Handicaps — ODH and ODMR/DD are developing common approaches to children whose families may seek services and supports from both agencies. This includes common outreach strategies, enrollment methods, tracking and recall systems, diagnostic criteria, and monitoring and quality assurance and as appropriate, enrolling them on MR/DD or ODJFS waivers.

Identified Transportation as a Priority
Reliable and timely transportation is a challenge for individuals with disabilities in both urban and rural areas. Transportation is necessary to access employment, health care, social activities and a variety of other aspects of life. The Ohio Department of Transportation (ODOT) and the Federal Transit Administration have been working to address human services transportation issues for several years with a renewed emphasis in recent months. The Federal Transit Administration recently unveiled a program called "United We Ride" that coordinates transportation resources and maximizes them to avoid duplication of effort and expenditure. ODOT is examining how this initiative may be implemented in Ohio.

As detailed in this section, a great deal has been accomplished during the past three years. Thousands of Ohioans are receiving better services and supports today than ever before. However, these data confirm that much more remains to be accomplished. Although progress is being made, many needs are not yet being met. In the spirit of Olmstead, we are committed to meeting those needs, and that's the purpose of the updated Ohio Access report.

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