Real Choice Systems Change
COMMONWEALTH OF N. MARIANA ISLANDS
Identified Problems with the State's Long-Term Care System
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Lack of data on the incidence of disabilities and long-term illnesses.
The Commonwealth lacks home and community services. There are no HCBS
waiver programs, no residential care for individuals with mental illness, and no
direct services for individuals with developmental disabilities.
Federally imposed capitation on Medicaid funds and statutory matching rate of 50
percent contributes to the lack of services.
A limited number of voluntary organizations offering family supports and a lack
of family support organization to address the needs of families.
Problems with recruiting and retaining qualified personnel, particularly special
education teachers, psychologists, physical, occupational and speech therapists,
interpreters and other specialized medical disciplines.
CNMI residents encounter major barriers in employing personal assistance
workers from abroad due to CNMI immigration and labor policy, which sets high
income thresholds that most persons who need specialist care cannot afford to
pay. There is also no domestic job category that specifically describes the duties
of a personal care attendant.
Lack of private, for-profit personal assistance service (PAS) providers and only
one private, non-profit PAS provider that work with persons with disabilities.
Due to lack of services, people who need services have to seek them off-island.
Once off-island, they often lack family support due to inability to pay for air
tickets.
Individuals not sent off-island for services are housed in disparate, isolated,
family homes and the care provided is of widely varying quality.
Parts to repair specialized equipment for persons with disabilities can take weeks
or months to obtain.
Perceived Strengths
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CNMI has a Council on Developmental Disabilities, the University Centers for
Excellence at Northern Marianas College, the Northern Marianas Protection and
Advocacy Systems, Inc., the Office of Vocational Rehabilitation Services and
Special Education Services. We are developing mental health policy to address
the needs of children and families.
A recently constructed transition living center (TLC) provides independent living
skills training and vocational rehabilitation services to enable persons with mental
disabilities residing in a psychiatric ward to transition to community living and
employment.
Parents of Children with Autism, a recently organized group, has begun a
campaign to gain community support for improved services.
Primary Focus of Grant Activities
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Establish three island centers to serve a diverse target population of people with
disabilities and facilitate their integration with the larger community.
Devise and demonstrate a model personal assistance services project.
Develop local capacity for personal assistance services through education and
training.
Provide technical assistance for improvements in personal assistance services.
Develop data collection and analysis capability.
Goals, Objectives, and Activities
Overall Goal. Expand CNMI long-term care capacities, directed by consumers and
innovative partnerships for systems change, and develop consumer access to, and control
of, personal assistance services.
Goal. Enable individuals with disabilities of all ages to live in integrated community
settings appropriate to their individual support requirements and preferences.
Objectives/Activities
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Establish community learning center and after-school summer program for
students and youth with disabilities to provide organized leisure activities
integrated with their peer groups.
Support existing groups, such as the Center for Independent Living, and establish
other peer support groups, such as adults, students and families, to implement
advocacy activities.
Establish one-stop resource information center to provide a venue for different
kinds of agencies and to provide information, application forms, brochures, access
to data, hotlines and other services.
Provide special services for transitioning consumers to the community after
discharge from hospitals and mental health wards, including support for the
families.
Goal. Create local capacity for personal assistant services through training and
certification.
Objectives/Activities
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Develop and implement education and training, including an assistive care
certificate curriculum, targeted to family caregivers and other local job-seekers to
increase the local capacity to provide services, to be sustained after the grant
through payment of fees.
Create eight PAS positions as a pilot project, and develop a fee-for-service
structure to sustain and expand PAS after the grant period.
Goal. Develop a consumer-driven body which will have legal authority to advocate for
services improvements through the legislature.
Objectives/Activities
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Provide training for consumers, service providers and professionals for systems
change initiatives.
Increase the number of self-advocates, and increase consumer control and
consumer choice through participation in the Self-Advocacy-Partners in Policy
Making Project.
Provide ADA Technical Assistance to educate consumers and family members
about their rights.
Goal. Increase access to assistive technology devices and provide training for consumers
and service providers.
Objectives/Activities
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Support a rotating 6–week lending program and augment the existing Assistive
Technology demonstration facility by requisitioning additional equipment.
Develop an Independent Living Transitional Accessible Model Home Facility to
serve as a demonstration and transitional center and a site for training in
independent living skills for the DD population and people with other disabilities.
Goal. Promote positive change in individuals with disabilities and their families by
improving physical, economic and social conditions.
Objectives/Activities
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Conduct needs assessment surveys and recommend accessible transportation
services that will support community living.
Purchase three accessible vans: one van to Saipan to expand existing service and
the other two to the islands of Rota and Tinian to commence a public
transportation program to provide services to people with disabilities and the
elderly.
Facilitate procedures with Department of Labor and Immigration to hire nonresident workers as personal assistants.
Goal. Increase access to, expansion and improvement of social services and supports,
economic development, community planning, and organization to enable individuals with
disabilities and those with long-term illnesses to obtain access to adult education, job
training, and quality of life activities.
Objectives/Activities
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Provide training for architects to achieve more ADA compliant residential and
public and buildings.
Develop a data collection and analysis capability to document the size and
conditions of the disability community, direct attention to relevant issues of
community concern, justify resource allocation, and improve the focus of service
programs.
Provide after-school program for remedial skills training.
Key Activities and Products
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Implement centers on three islands to function as venues for coordination and
delivery of PAS. Each island will designate stand-alone facilities for dedicated
center use.
Establish a community governance initiative supporting comprehensive systems
change.
Design and implement a model PAS project with a sustainable fee-for-service
structure.
Develop and implement PAS education and training to meet demand and address
personnel shortages.
Collect and analyze data on the CNMI population with disabilities or long-term
illness.
Consumer Partners
The Consumer Task Force for Systems Change comprises 12 primary and secondary
consumers, including representatives from Saipan, Tinian, and Rota Parent Organization
also known as STARPO (formerly Parents Association of Children with Autism).
Consumer Partners and Consumer Involvement in Planning Activities
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The Consumer Task Force organized and undertook a needs assessment process
with service provider agency participation and support. The process took place
over 21 days and culminated in the 3–year grant workplan.
The Task Force determined appropriate budget allocations for each activity, and
identified in-kind support exceeding $400,000.
The consumers alone determined service priorities for each grant project.
Consumer Partners and Consumer Involvement in Implementation
Activities
The Task Force will be responsible for program implementation either directly or through
contractual partnerships, and will operate as the core leader of a community governance
initiative involving the CNMI disabilities community. The Task Force will participate in
and/or direct:
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Supervision and evaluation of work done on its behalf by subcontractors.
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Program demonstrations and projects.
Public Partners
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Assistive Technology Project.
Department of Labor and Immigration.
Governor's Office.
Medicaid Office.
Office of Vocational Rehabilitation.
Northern Marianas College (NMC)—University Center for Excellence (UCE).
Children's Developmental Assistance Center.
Public School System Special Education and Head Start.
Office of the Mayor.
Office on Aging.
Community Guidance Center—Transition Living Center.
Northern Marianas Housing Corporation.
Private Partners and Subcontractors
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Center for Independent Living.
Saipan Call-a-Ride.
AssistGuide, Inc.
Northern Islands Company.
Public and Private Partnership Development/Involvement in the Planning
Phase
Public
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Public School System Special Education and Head Start, Children's
Developmental Assistance Center, the Medicaid Office, the Office of Vocational
Rehabilitation, Northern Marianas College University Center for Excellence and
the Office of the Mayor organized and undertook a needs assessment process with
the Consumer Task Force.
The public partners identified technical issues pertaining to infrastructure needs,
barriers and model approaches.
Private
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Saipan Call-a-Ride undertook a needs assessment process with the Public Partners
and the Consumer Task Force.
Northern Islands Company, a consultant, was subcontracted to write the grant
application.
Public and Private Partnership Development/Involvement in
Implementation
Public
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Office of Aging will be involved with the creation of the one-stop information
and referral centers on Tinian Island and Rota Island.
Northern Marianas College will provide direct technical assistance to each island
center.
NMC will develop and implement education and training services to increase the
local capacity to provide services.
NMC-UCE will develop a data collection and analysis capability to document the
size and conditions of the disabilities community, direct attention to relevant
issues of community concern, justify resource allocation, and improve the focus
of service programs.
The Department of Labor and Immigration will facilitate the employment of nonresident workers to provide PAS.
Northern Marianas Housing Corporation will provide training on accessible
housing.
Private
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AssistGuide, Inc. will collaborate with NMC-UCE to develop a data collection
and analysis capability.
The Center for Independent Living will operate, manage and assist with training
in independent living skills at the future Independent Living Transitional Model
Home Facility.
Existing Partnerships That Will Be Utilized to Leverage or Support Project
Activities
Under the Real Choice Grant, the existing CNMI Council on Developmental Disabilities'
Assistive Technology Project will expand its activities and play a major role in assisting
with the design and purchase of assistive technology devices for accessible homes to be
housed at the Independent Living Transitional Model Home Facility, and provide
assistive devices for limited-term use through an inter-island equipment lending program.
Oversight/Advisory Committee
The Consumer Task Force will direct and evaluate subcontractor work products, progress
and outcomes, and interface with the lead agency, the CNMI Council on Developmental
Disabilities.
Formative Learning and Evaluation Activities
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The basic approach is a check and balance system, which will incorporate the
time frames, milestones, expected outcomes for each partnership, adaptive
measures to make program adjustments, and consequences of inadequate
performance.
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The Task Force will evaluate and report on the work of the contractual partners in
a formative learning process, primarily using quarterly consumer satisfaction
surveys with progress reporting by the subcontractor partnerships.
The service provider agencies affiliated with the Task Force will evaluate Task
Force performance in governance, the three centers, demonstration projects and
subcontractors work components of the program. This internal cross-assessment
process will enable the recognition of problems and provide a regular forum to
address solutions, program refinements and substantive changes throughout the
grant program period.
Evidence of Enduring Change/Sustainability
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The creation of physical locations (the island centers) where agencies and
consumers can meet together as a community will encourage consumers to take
active roles in obtaining services and directing improvements in the social
services network of the community.
The island centers will provide both a venue and coordination of services for
providers which will be self-sustaining.
Capacity development will include the development of an assistive care certificate
curriculum that can be used after the grant period ends.
The first-time availability of services resulting from the Real Choice Grant
program will demonstrate significant cost savings over the current practice of
obtaining services outside the CNMI, and represents fundamental systems change.
The basic CNMI Medicaid program changes underway will provide coverage for
on-island home health care for the first time. Sources of funding for PAS will
include MAP and possibly a waiver, which is now being considered. Medicare
would pay for home care services as well as assistive technology
equipment/durable medical equipment.
Representations to Congress to remove the federal Medicaid services cap and
adjust the statutory matching rate from 50 percent to 77 percent, if successful, will
result in more funding for home health care and PAS.
Geographic Focus
CNMI-wide.