The Demonstration to Maintain
Independence and Employment
Assisting Individuals with
Disabilities Remain Employed
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What is DMIE?
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DMIE provides medical and employment services to
workers with potentially disabling health conditions.
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The DMIE uses a rigorous experimental model, in
order to determine the effect of health and
employment supports on ◙
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Health
Dependence on public benefits such as federal Social
Security disability programs
Why DMIE?
 A person’s health affects their ability to work.
 Many uninsured workers with disabilities lose
employment and turn to federal assistance.
 By 2003, disabled US workers accounted for nearly
$65 billion of $77 billion in federal disability benefits.
 Traditional Medicaid programs for people with disabilities
do not provide “preventive care”.
 DMIE offers a unique opportunity to keep workers
healthy and working.
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“Gold Standard” Evaluation
 Rigorous experimental/randomized control design to
ensure strong, policy relevant data
 Evaluation of quantitative and qualitative data, including:
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Changes in health status
Income
Employment
Quality of Life
Disability Status
Cost-offsets
Program Cost effectiveness
 Each state must have an independent evaluator
 Mathematica Policy Research performs the national
evaluation of DMIE
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Why Continue DMIE?
Preliminary findings suggest:
◙ Potential to reduce public expenditures for disability
benefits (less people applying)
◙ Potential to reduce employer costs related to worker
health problems
Provides data to support development of longer
term reforms
May provide a replicable infrastructure of
services to prevent disability
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Why Do We Need an Extension?
To move from a “one time experience” to
conclusions, States need more time
Longer studies will produce –
◙ Better measure of key outcomes (health,
income, disability status, cost offsets, cost
effectiveness)
◙ Better data for policy development
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Need to Act Now
 If there is a gap in funding, it will be difficult to restart
these on-going projects
 CMS must have time to amend grant awards
 Revised terms and conditions will be needed
 Match must be secured
◙ Bi-annual State budgeting processes will need to anticipate
extension or termination
 States will need to amend vendor contracts
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For More Information
Nanette Relave, Director
Center for Workers with Disabilities,
NASMD
◙ NRelave@aphsa.org
◙ 202-682-0100 x241
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The Kansas Demonstration to
Maintain Independence &
Employment
Preliminary findings about
participants’ health, service utilization
and employment
Jean P. Hall
University of Kansas
Target Population
 Enrollees in the Kansas High Risk Pool
health insurance program; DMIE
provides Medicaid-like coverage as
wraparound to the high risk plan,
which has relatively limited coverage
 Historically, people in the Kansas high
risk pool have transitioned to federal
disability benefits at a rate eight
times that of the general population
The Kansas High Risk Pool
 Coverage of last resort for Kansans who
are medically uninsurable in the private
market (one of 34 pools nationally)
 As a non-group plan, coverage is more
expensive and less comprehensive than
employer-based insurance
 A 25 year old non-smoking female would
pay $624/month in premiums for a plan
with a $1500 deductible and 30%
coinsurance
Preliminary Findings About
Study Participants
80% have at least some college
Median annual income of $30,000
70% are self-employed
Despite risk pool coverage, 27% report having
medical debt
 Many report delaying or forgoing care due to
lack of coverage or expense
 Experience a range of serious and potentially
disabling conditions including: diabetes, mental
illnesses, cardiovascular disease, cancers and
back and joint conditions
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From participants
 About their coverage through the high risk pool:
“We’re in a Catch-22: if you can’t get your health
better because the insurance doesn’t cover
services, then you can’t get a full-time job, so
then you can’t get good insurance to help get
your health better.”
“I have car accident insurance, not wellness
insurance.”
 About the DMIE:
It [the DMIE] increases your quality of life. You
stay healthier because you have the enhanced
benefits to help you stay healthy.
Case Studies
 Ms. A has Crohn’s disease and arthritis in
her feet and ankles. The DMIE has allowed
her to get the adaptive shoes and leg
braces she needs to be able to work. She
reports that, without the DMIE, she would
have applied for SSDI and been fully
disabled by now.
 Mr. B says the DMIE has improved his life:
“Being able to have that surgery for a
detached retina and being able to see again
was fantastic. I am a music teacher so it
would have affected me greatly had I not
had it repaired.”
Need for an extension
 Although a small minority of Americans
acquire a disability immediately prior to
applying for Social Security disability, the
large majority experience a gradual
worsening of medical conditions over
time; health insurance coverage is a
major factor in the decision to apply for
disability benefits (Miller 2005).
 Hadley (2003) found that improving
health status from “poor to fair” to “good
to excellent” would increase work efforts
and earnings by 15 to 20%.
Without an extension
 Programs will not have sufficient time
to demonstrate:
 Prevention of transition to federal
disability programs
 Increases in work efforts and health
status
 An important part of the Ticket
legislation, i.e., disability prevention,
may not be realized and federal
disability rolls will continue to grow
Kansas DMIE contacts
 Mary Ellen Wright
Program Director
Kansas Health Policy Authority
MaryEllen.Wright@khpa.ks.gov
(785) 296-5217
 Jean Hall
External Evaluator
University of Kansas
jhall@ku.edu
(785) 864-7083
Minnesota’s Demonstration to Maintain Independence and Employment
Stay Well, Stay Working
Minnesota’s Demonstration to
Maintain Independence and
Employment
Minnesota’s Demonstration to Maintain Independence and Employment
The Commitment to a DMIE
1999 – Congressional Authorization
2003 – MN Legislature Authorized DMIE
2004 – MN Submits Proposal to CMS
2005 – Planning Grant Received
2006 – Protocols Approved (July)
2007 – Enrollment Began (January)
2008 – Enrollment Ends (8-31)
2009 – Six-Month Notification to Enrollees (3-31)
2009 – Demonstration Authority Ends (9-30)
Minnesota’s Demonstration to Maintain Independence and Employment
Desired Outcomes :
Accessible, Responsive, Outcome
Driven System
• Community Mental Health Reform
• Managed Care Pilots Integrating Health
Care with Home and Community
Based Services
• Health Care Reform
Minnesota’s Demonstration to Maintain Independence and Employment
Who is Enrolled? (Current N=1000+)
Most common mental health diagnoses:
Depression
Anxiety Disorder
Bipolar Disorder
95% desire to keep working
Average monthly income: $1,577.31
13% college graduate - 43% high school/GED
9% married; 27% divorced; 59% never married
SF12* = 47 physical health, 36 mental health
* SF-12 is a measurement of overall health, including mental health. Scale of 0-100
(poor to excellent, 50 avg. for general population)
Minnesota’s Demonstration to Maintain Independence and Employment
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Minnesota’s Demonstration to Maintain Independence and Employment
Value of the DMIE
• Building Stronger Community
Capacity
• Intervention Before “deep-end”
Services
• Evidence Based Practice and
Person Centered
Minnesota’s Demonstration to Maintain Independence and Employment
DMIE Is Working
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Kim was able to get back on her anxiety medications and
reports more stability with her employer.
Kristin was drinking at work. She went through in-patient
treatment and was able to keep her job.
Jeff has difficulty interacting with people due to schizophrenia.
He was able to get a job as a delivery driver and is employed
30 hours per week.
Mary’s Fibromyalgia and late night shift were causing fatigue.
An employment counselor helped her get a day shift close to
home so she can continue working.
Todd knew he needed treatment that he wasn’t able to access
and reported feeling suicidal. Through DMIE he received the
treatment he needed.
At least 9 people have reported choosing DMIE instead of
applying for a disability determination.
Minnesota’s Demonstration to Maintain Independence and Employment
Moving Forward
“This is good common-sense policy:
providing preventive health coverage to
working individuals with serious medical
conditions before such conditions
worsen to disabling level.”
Senator Patrick Moynihan,
Congressional Record 11-99
Minnesota’s Demonstration to Maintain Independence and Employment
What to Leave Here With…
“For the first time in over a year, I
feel hope. With the services and
support DMIE offers, I can begin to
manage my chronic conditions
better, find a permanent job, catch
up financially and improve my life.”
Barb - DMIE participant
3/20/08
Minnesota’s Demonstration to Maintain Independence and Employment
Minnesota DMIE Contact
• MaryAlice Mowry, Director
Stay Well, Stay Working
– Maryalice.Mowry@state.mn.us
– (651) 431-2384
Texas DMIE
Texas Department of State Health Services
Current Reality
• 28 percent of working adult Texans are uninsured
• Uninsured Texans with disabilities turn to federal programs for help
when they become unemployed.
• This increases federal costs and erodes the local tax base which
supports health care.
• 250,000 working age Texans with disabilities receive SSI (average of
$412/ mo per person in 2005)
• 380,000 Texas workers with disabilities receive SSDI (average of
$924/mo in 2005)
• 345,500 working age Texans with disabilities were on Medicaid in
2007. Expenditures were $3.5 billion. (In Harris County 48,600 cost
$375.5 million)
04.02.08
Texas DMIE
• A model which can work in states where county
governments address the health needs of low
income workers
• Largest study population among DMIE projects
(over 1600 participants)
• Randomized controlled trial
• Intervention group receives enhanced medical
and vocational services
04.02.08
Current Texas Site: Houston
04.02.08
State / Local Partnership
Harris County
Hospital District
Develop/ operate
DMIE Health
System
Provide match
for Medicaid-like
services
UT Austin
State
Oversight
Federal Liaison
Manage Project
Conduct
independent
evaluation
DMIE data
system
Recruitment
04.02.08
Who’s in Texas DMIE?
• Adults (21 – 60) with disabling conditions
— Severe mental illness (schizophrenia, bi-polar
disorder, major depression) – 12%, or
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— Major physical conditions (e.g., diabetes, heart
disease, MS, etc.) PLUS a behavioral health illness
(depression, etc.) – 88%
Low income – 90% are below 200% poverty, 60% are
below 100% poverty
Limitations in performing daily living tasks (40%)
A strong desire to continue working (80-90%)
Part or full-time jobs (20% are health care workers)
At significant risk of dependence (over 400 candidates
applied for disability before they could be recruited into
the study)
04.02.08
Supporting Wellness
• Health services (physician, hospital, etc. )
• Enhanced health services
— Prescription medicine
— Enhanced psychological and neuropsychological
assessments
— Improved access to outpatient mental health services
(expedited office or outpatient visits)
— Chemical dependency treatment services
— Expanded Durable Medical Equipment
— Preventative and restorative dental treatment
04.02.08
Supporting Independence
• Individual planning addressing life and health issues
• Advocacy, direct services, motivational interviewing, coordination
and intervention
• Assistance in connecting to other community resources
• Employment/Vocational supports including:
— Vocational Assessment/Evaluation
— Collaboration with an Employer
— Vocational Support Groups
— Collaboration with Family/Friends
— Vocational Treatment Planning/Career Development
— Vocational Counseling
04.02.08
Texas DMIE Enrollment
04.02.08
How It’s Working
• Linking workers to vital health care services
• Providing help to gain, keep, improve employment
• Building upon local systems of care by better
coordinating existing resources
• Hundreds are now getting help. Success stories include:
— Mental health care and employer education result in secure and stable
job for formerly suicidal person
— Orthopedic shoes, health and job counseling allow a severe diabetic to
keep working
— Health counseling, career planning result in full-time job for formerly
unemployed person with multiple physical/mental disabilities
04.02.08
Future Texas Plans
Texas plans to extend / expand DMIE, should extension
be included in the federal budget
— Continue Houston project through 2012
— Add second site - Bexar County (San Antonio) –
important to determine if success can be
replicated in Texas
For more information contact:
Dena Stoner, State Project Director
(512) 206-4851
dena.stoner@dshs.state.tx.us
04.02.08
Hawaii Demonstration to Maintain Independence and Employment
University of Hawai`i - Center on Disability Studies
April 15, 2008
Partnership for a Healthy Workforce
Strategy: Partner with employers to find ways to maintain a
healthy workforce
Committed Employers $6.7 Million:
Hawaii Business Health
Council
Times Supermarket
Roberts Hawaii
Longs Drug Store
Roberts Hawaii
Hawaiian Electric
Company, Inc
Central Pacific Bank
…and many more
Committed Agencies $9.1 Million:
CMS
Hawai`i Dept of Human
Services
Hawai`i Dept of Health
Oahu WorkLinks
University of Hawai`i – CDS
Hawai`i DLIR
HI Division of Voc. Rehab
Hawaii Disability Rights Center
Why do Employers Care?
Prevalence of diabetes in U.S.
• Approximately 17.5 million are diagnosed
• National cost of diabetes exceeds $174 Billion
– $116 billion in excess medical expenditures
– $58 billion in reduced national productivity
Prevalence of diabetes in Hawaii
• About 107,000 people living with diabetes
• Estimated annual costs are more than $1 billion
– $764,400,000 for medical costs
– $273,600,000 for indirect expenses – loss of productivity
Source: Diabetes Care, Volume 31, Number 3, March 2008 & National Diabetes Education Program www.ndep.nih.gov & National Diabetes
Education Program, NIDDK, National Diabetes Fact Sheet HHS, NIH, 2005, www.ndep.nih.gov
A Possibility for Prevention
Goal: Develop, implement, and evaluate
interventions that are intended to improve
health care coverage and employment
services for working adults with diabetes and
potentially disabling conditions
Target Population:
• Individuals diagnosed with diabetes or has
a Hemoglobin A1c 6.5+
• Employed adults (40+ hrs. per month)
• Resident of Oahu
Life Coaching – Benefits and Supports
Intervention: Off-site diabetes self-management support services.
Participants will meet with:
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Pharmacist (Medication Therapy Management)
Life Coach (Use of a laptop and online coaching tool
to track goals)
Financial Compensation:
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Medical, drugs, and supplies related to diabetes
Other optional services include:
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Certified Diabetes Educator
Dietitian
Fitness Membership
Desired Outcomes for our Community
People working and living with diabetes will:
• Improved health and productivity
• Increase work hours
• Reduce absenteeism
• Reduce employee turnover
• Improve job satisfaction and morale
Diabetes is Preventable and Treatable!
Listen to Our Participants
“I’ve lost over 25 pounds and feel better overall than I did prior
to participating…my HbA1c has dropped from 7.0 to 6.2 percent
on my last blood test.” – Rodney
"It has given me positive feedback, encouraged me to set
measurable short term goals to keep that positivity going
strong." – Anonymous
"Great program, kept me motivated and thinking about what I
can do to help myself live a better/healthier life." – Brian
"With a life coach, you will have someone who can provide a
different perspective, help set goals, and provide other
resources that may help you control this affliction.“
– Anonymous
Mahalo nui loa!
Contact information:
Rebecca Rude Ozaki, Ph.D.
1-808-956-9376
rozaki@hawaii.edu
www.livehealthyworkwell.org
University of Hawaii at Manoa – Center on Disability Studies
1776 University Ave., UA 4-6
Honolulu, HI 96822
Iowa DMIE:
Former inmates with mental illness Re-entry employment and support
Jennifer Vermeer
Assistant Medicaid Director
Iowa Medicaid Enterprise
Iowa Department of Human
Services
Iowa DMIE – the benefit
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DMIE Purpose – prevent disability and lifetime
dependence on disability programs; support
independence and employment.
Iowa is focusing on a unique population – individuals
re-entering community from prison, with mental
illness who are willing and able to be employed, but
needing supports.
Studying the outcomes of this population will provide
significant national benefit, because all states face
these problems.
Iowa – Need DMIE grant extension
to start
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Unlike the other states, Iowa has just received grant
approval.
Iowa needs the 5 year extension in order to start and
implement our program.
No federal funds will be used for the prison services
prior to release. Iowa is investing a significant 100%
state funds contribution to the project for the re-entry
services needed prior to release from prison.
The Problem: Lack of supports land
mentally ill in prison
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Nationally, as many as 1 in 5 prison/jail inmates are mentally ill. In
Iowa, 1 in 3 inmates are mentally ill.
Former inmates have little to no access to mental health treatment
outside prison, and are far less likely to be employed than other
inmates (29% for mentally ill vs. 69% for other inmates) .
Without supports, more likely to eventually become permanently
disabled and dependent upon public assistance programs.
National interest in ‘re-entry’ or rehabilitation programs for those
coming out of prison. (‘Second Chance Act’ just signed). Mentally
ill inmates pose particularly difficult challenges for re-entry and
success in community.
Iowa’s DMIE Project
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Target group - mentally ill inmates leaving prison with
work history and ability to work.
Grant will provide appropriate community mental
health and vocational supports to keep mentally ill
former inmates employed, independent, and in the
community.
Demonstrate higher employment rates, prevention of
permanent disability.
Iowa DMIE: Multi-Agency partnership
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Project is a partnership between 4 agencies:
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DMIE has a very rigorous evaluation methodology
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DHS, Iowa Workforce Development, Department of
Corrections and University of Iowa.
Experimental design & Control groups
Evaluation by University of Iowa
Over 5 years - $28.2 Million State funds, $56.7 million
DMIE funds.
Iowa DMIE Program
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Prior to release, intensive Life Skills training and Reentry/transition planning with the inmate to prepare for
community living (funded with 100% state funds).
DMIE - Community Supports:
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Supported employment assistance – help planning for and
finding a job for when released. Includes supports for the
employers.
Medicaid coverage for mental health treatment and
medications, includes intensive care management.
Specialized community supervision.
Employment is required for continued participation.
Iowa DMIE Contact
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Jennifer Vermeer, Assistant Medicaid
Director
Iowa Medicaid Enterprise
Iowa Department of Human Services
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JVermee@dhs.state.ia.us
(515) 725-1144
Questions?
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