What is community-based living?
Community-based living means having a life in the community rather than in an institution. The idea of community-based living has resulted in the closure of institutions across the United States. It has been supported by significant legislation at the federal level, including most recently, the Olmstead Act.
What are community-based services?
Community-based services are support services that are provided for people with disabilities and the elderly who live in their own homes and communities. Community-based services provide help for all aspects of a person's life and may include the following:
- Residential services and facilities, including supervised apartments or group homes.
- Personal assistance services, including assistive technology.
- Care planning, case management, and a comprehensive individualized plan, that includes a case manager, the person in need of services, and other people that support the individual.
- Day programs, including placement in activity centers and adult skills programs.
- Vocational services, including supported employment programs, job training and placement, and job coaching.
- Other quality of life services, such as recreation, leisure, and transportation.
What are personal assistance services?
Personal Assistance Services (PAS) include any assistance that is provided for people with disabilities to help them with everyday activities. These services may include providing assistance to enable an individual to participate in sports, hobbies, clubs, and other community activities and events.
What is the Olmstead Decision and how does it affect community living?
The Olmstead Decision concluded that under Title II of the American with Disabilities Act (ADA), all states are required to place persons with mental disabilities in community settings rather than institutions. There are a number of factors that determine when this is appropriate. To view the complete text of the Olmstead decision, go to: supct.law.cornell.edu/supct/html/98-536.ZS.html.
Understanding Long Term Care
Reforming Michigan’s long term care system is a common goal.
Michigan needs to reform its long-term care system into a system which supports Baby Boomers in their homes as they age. We cannot afford to nor should we continue to rely on nursing homes as the first source of services for people who could continue to live in their own homes if they had supports. Persons with disabilities likewise need access to supports to live independently in their own homes.
Long-Term Care—Money Should Follow the Person
- Persons with disabilities and many seniors rely heavily on Medicaid programs to provide them with the services and supports they need to live, work, and participate in their communities. Preserving and strengthening those programs ensures quality of life for Michigan’s most vulnerable citizens and is cost effective to the State. People’s rights to receive long-term supports in the most integrated setting consistent with their needs has been affirmed by the United States Supreme Court in its Olmstead decision.
The Medicaid Long Term Care (LTC) Reform task force will need to develop a consensus on the top LTC reform priorities identified by aging and disability advocates. These top priorities are:
Create a single point of entry for LTC options.
Many people think nursing home care, which will cost the state $1.29 billion this fiscal year, is the only option for themselves or their loved ones when they need assistance. A single point of entry could screen and divert those with long-term care needs from nursing homes to community-based care, services, and supports and provide information on options for those with more extensive needs. After New Jersey implemented a single point of entry process, it realized a 10% reduction in nursing home census numbers.
Determine level of need with a universal screening tool.
As a provision of the Olmstead lawsuit settlement, the state must develop a universal screening tool that will guarantee that people using the most intensive, expensive services actually need them. In 2002, the Colorado Legislature enacted a range of progressive measures including a universal screening tool. Colorado saved several million dollars the first year alone simply by implementing this tool, which diverted people from nursing homes to community-based care. The former Medicaid Director in Colorado estimates that admissions to nursing homes dropped by 20%.
Allow money to follow the person.
“Money follows the person” allows an individual needing long-term care to take the money spent on their care and receive needed services in any setting. Michigan’s long-term care system is unbalanced and lacks choice. Funding for nursing home care more than doubled between FY 1997 and FY 2002 in Michigan while funding for community-based care remained stagnant. Michigan ranks among the highest in the nation for percentage of LTC spending on nursing homes (81% in FY 2004) as opposed to community-based care.
The long-term care delivery system for those with chronic conditions is complex and confusing; care is often fragmented, less effective than it might otherwise be, and more costly. Care coordination is necessary to help consumers navigate between a variety of LTC services, supports and settings. Individuals who want to leave restrictive and costly settings should have access to services and supports to make the transition. Such services are budget neutral, and can be paid for by Medicaid. Using data compiled by Disability Network/Michigan, the average per person savings by transitioning people to the community was $26,132 in FY 2003. Other states where the shift has been on money following the person into the community have seen dramatic cost savings.
Restructure financing of the LTC system.
People with high needs receive higher payments for services, regardless of care setting and those with lower needs receive lower payments. This is commonly referred to as case mix reimbursement and creates a fairer funding stream. According to a GAO report on Medicaid nursing home payments, other states have designed their payment methods to encourage efficient and economical delivery of care. The same report posits that adjusting rates for case mix may encourage providers to accept consumers who require more expensive care while also providing states with a tool to compare costs more appropriately. This financing structure should apply to the continuum of Medicaid-funded long-term care services, including home and community-based services.
Create the groundwork for a qualified, reliable long-term care work force.
Persons with disabilities and many seniors rely on committed, competent workers to provided needed services in their homes and in the community. We are facing a growing labor shortage of people willing to provide this care. Some estimate that by 2010, Michigan will need an additional 40,000 home health aides, certified nursing assistants, and personal care attendants in order to meet the needs of our aging population.
Because of poverty-level wages (an average of $6 per hour in Michigan and just $5.15 in Wayne County) and a lack of benefits including health insurance, turnover rates in home health care hover at an astonishing 65%. More money and better benefits can be found working for McDonalds. Michigan must place a priority on increasing pay and benefits for these vital positions. With the establishment of Michigan’s Quality Community Care Council, an organization designed to link home care workers with people needing home and community-based care, Michigan may soon begin to address some of the critical issues facing the independent provider in the LTC workforce.
The Home Help program is another critical home and community-based supports program for persons with disabilities and many seniors, which has been successful in preventing many people from going into nursing homes. Funding for Home Help has been targeted for cuts in recent months, putting many people’s health, safety and community living status at risk. FIA caseworker assessments of consumers’ needs for Home Help services are often unrealistically limited, and create tremendous hardship. This action represents the long standing problem of eliminating services without serious analysis of the impact. The system provides no incentive for overworked caseworkers to prevent unnecessary institutionalization, which has contributed to the steep increases in the cost of LTC.
Persons with Developmental Disabilities and Mental Illness
People with Developmental Disabilities and Mental Illness should also have access to a comprehensive, statewide array of supports and services, consistent with principles of self-determination. These consumers have lost significant ground in recent years in their ability to access health care, mental health services, and supports for independent living.
Alternative Services that have been available through community mental health (CMH) service providers include personal care, transportation, job coaching, preparation for employment, family support, and respite care. They are now threatened by budget cuts. Without such services, people are at risk of having to move to far more expensive segregated settings. The State should ensure alternative services will continue to be available, and that the CMH system understands how to implement them. The State must ensure compliance among community mental health service providers with the Mental Health Code’s requirement for person-centered planning. The State needs to focus upon preventive services, through such initiatives as the mental health prevention services pilot funded previously in the DCH budget. The pilot targeted children with emotional illness for an array of demonstration programs.
Funding for mental health services for adults and children must be increased. The array of services for people with mental illness, dismantled over the last decade, must be reestablished,
with a focus on self-determination and the provision of care in the most integrated setting consistent with the consumer’s needs and choices.