CIL-NET Presents…
Implementing and Enforcing Olmstead
A National Onsite Training
The California IL Approach to Olmstead
May 11, 2011
Atlanta, Georgia
Presenter:
Laurel Mildred
California Foundation for Independent Living Centers (CFILC)
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Who We Are
• Based in our state capitol of Sacramento, the
California Foundation for Independent Living
Centers is a statewide, non-profit trade
organization representing 24 Independent
Living Centers.
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CFILC
• The mission of the California Foundation for
Independent Living Centers is to advocate for
barrier-free access and equal opportunity for
people with disabilities to participate in
community life by increasing the capacity of
Independent Living Centers to achieve their
missions.
• The statewide approach has resulted in strengths
in public policy, organizing and technological
innovation.
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Topics
I.
CFILC’s Olmstead Project
II. Our 2010 “Olmstead Summit”
III. Key Policy Work
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I. Our Olmstead Project
Background
After receiving ILC community input, the State
Independent Living Council and the California
Department of Rehabilitation made Olmstead
implementation a priority, and designed several
grant opportunities intended to advance
implementation using American Recovery and
Reinvestment Act (ARRA) funds.
One of these projects emphasized public policy.
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Funded Through ARRA
• In 2009, CFILC applied for and was awarded
the public policy grant from our state
Department of Rehabilitation. It is a two-year
project.
• Our proposal was to re-start a defunct Olmstead
Coalition, and to bring policy and training
resources to ILCs and other advocates in order
to strengthen their capacity to move Olmstead
forward.
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Californians for Olmstead
We called our project
CALIFORNIANS FOR OLMSTEAD.
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Mission Statement
• The mission of Californians for Olmstead is to
work toward community inclusion of all people
with disabilities in California through the
implementation of the Olmstead decision. We
do this by working with people with disabilities
to secure public resources and quality support
needed for people to live full and equal lives in
the community.
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Broad Strategies
• Coalition Building: The Project provides a context
for ILCs to work with other organizations, such as
aging, disease-specific, and poverty and civil rights
advocates.
• Deepen Policy Focus: The Project has provided indepth focus on key issues, and informs and supports
the ILC “Systems Change Network” as well as
Coalition partners.
• Coordination with Transition Services: The
Project connects with ILC’s in their role as transition
services providers, bringing their hands-on experience
into policy advocacy.
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Major Project Activities
• Develop Communications Structure, Website,
Facebook Page, Listserv
• Revitalize Olmstead Coalition
• Hold Monthly Teleconference Meetings
• Achieve Public Policy Outcomes (4-6 positive
and 4-6 defensive)
• Take Advocacy Action and Develop Toolkits
• Organize a Series of Trainings
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Our Initial Assessment of Barriers
•
•
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Lack of specificity and accountability in California’s
Olmstead Plan.
Lack of a “system” in the long term care system,
characterized by fragmentation of services and
funding, with implications for the individual
consumers and the overall budgets for services.
Policymakers’ acknowledgement of the effectiveness
of the In Home Supportive Services (IHSS) program
in reducing dependence on nursing home services,
juxtaposed with policymakers reduction in funding for
IHSS.
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Our Initial Assessment of Barriers,
cont’d.
•
•
•
Small federally-funded pilot programs, but no
overall commitment to expanding those
programs to other areas or other populations.
Huge increases in spending for nursing homes,
whose funding is separate from home and
community-based services.
Lack of legislative knowledge and leadership
on Olmstead and community integration, as
compared to legislative mandates in other
states.
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Our Initial Assessment of Barriers,
cont’d. 2
•
•
Duplicative use of assessments for long term
care users and lack of true care management
for those who want it.
Lack of affordable, accessible housing as a
major barrier to community integration, with
no coordinated effort to overcome this barrier.
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Situational Analysis:
All Budget, All the Time
• California’s ever worsening budget problems have
put advocates on constant defense over a period
of years.
• Cuts have impacted all services in the community
system of care, and taken together, the UCLA
Center for Health Policy estimated that the
proposals “turn back the clock 30 years” on
California’s long-term care system. Some of these
cuts have been defeated, others have become the
new normal.
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And It’s Not Over Yet
• This year Governor Jerry Brown proposed, and the
Legislature has adopted, $12.5 billion dollars in
statewide program cuts (to all programs and
services). Balancing our budget now requires $12.5
billion from extending current temporary taxes that
are set to expire.
• The revenue piece has precipitated a large political
battle.
• Without resolution, California faces an “All Cuts”
budget of an additional $12.5 Billion in reductions.
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And It’s Not Over Yet, cont’d.
• A key challenge of the Project has been to stay
active and relevant on fighting devastating cuts
while holding the space for a longer-term vision
of system change.
• We tried to bring valuable budget resources to
support advocacy, stay involved in the key longterm system change issues, and set careful
priorities for issues to go into in more depth.
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How We Set Policy Priorities
•
•
•
•
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Foremost Consideration – Achieving Grant
Deliverables
Organizational Priorities – CFILC ED Coordinated
Work with Systems Change Network and Other
ILC Projects
Expressed Concerns of ILC Directors
Expressed Concerns of Coalition Members
Project Manager’s Experience – Discretion to
Pursue Critical Policy Issues
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Our Training Series
These will be live, interactive, accessible webinars
(Elluminate training platform)
1. Critical Issues in Olmstead Implementation
Overview, Policy Framework and Review of Litigation
2. There's No Place Like Home
The HUD HOME Investment Partnership Presents an
Opportunity to Support Housing for People
Transitioning From Institutions – with Steve Gold
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Our Training Series, cont’d.
3. The Game-Changing Strategy
Building an Effective System of Long-term Services and
Supports through Implementation of the Federal
Affordable Care Act
4. Follow the Money
Using Cost-Effectiveness in Advocacy for Long-term
Services and Supports
5. Getting the Message Out
Enhancing Advocacy Through Effective Communication
about Olmstead
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Final Project Outcome
• Our final deliverable, due in September, is a
blueprint for future action.
• This report will be posted on our website.
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II. California Olmstead Summit
• Our Major Year-One Project was to Convene
Disability Community Leaders and Advocates
from Around the State Around Issues of
Olmstead Implementation
• We Planned, Collaborated and Shared Costs with
our Protection and Advocacy Organization,
Disability Rights California
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II. California Olmstead Summit,
cont’d.
• In September of 2010, 50 Key Leaders Gathered
from Around the State to Hear a Keynote from the
Department of Justice and Participate in the
Summit.
• Day 1 Included 4 Policy Panels Featuring State and
National Experts
• Day 2 Included a Training in Communications by
Public Works; the DEMOS Center for the Public
Sector
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Overview Panel
• Reviewed budget cuts that had an Olmstead
impact
• Assessment of political climate from a key
legislative staff ally
• Overview of long-term care provisions of health
care reform
• Academic research that would support removing
the institutional bias of Medicaid
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Legal Strategies Panel
• Disability Rights California Reviewed Olmstead
Litigation in California
• National Senior Citizens Law Center Reviewed
National Medicaid Litigation
• The Bazelon Center for Mental Health Law
Reviewed Critical National Olmstead Litigation
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Panel on Long-term Care System
Reform
• Review of Advocacy from 1999 to Now
• Using Cost-Effectiveness Arguments in Advocacy
• Recommendations from the Author of: Long-term
Care Reform in California: Recommendations of the
Home and Community-Based Long-term Care Report
http://www.hcbs.org/moreInfo.php/source/152/doc/2730/Ho
me_and_Community-Based_Long-Term_Care:_Recommend
• Strategies for Moving a Reform Agenda
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Successful Models Panel
• The Developmental Disability System (Our
Lanterman Act)
• Mental Health Community-Based Models
• An Effective County-Based System – San
Francisco
• Expanding Successful Transition Services in
California (California Community Transitions –
our Money Follows the Person program)
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What We Learned from DEMOS
Communications Training
• Research-based Communications Strategies for
Conveying the Positive Role of Government in
Addressing the Common Good
• Dominant Stories Shape Understanding (Hidden
Reasoning)
• Critical Role of Master Narratives
• Ways We Communicate that Make Things Worse
(For Example, Triggering Independence Rather
than Interdependence, Conveying Stories of
Desperation Rather than Aspiration)
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What We Achieved
• Successful Collaboration with DRC in Planning
Event
• Developed Outstanding Content
• Increased Relationships and Cross-Pollination of
Work
• Excellent Participation and Excitement
• Set Stage for Participation in Larger FoundationSponsored Collaborative Working on Long-term
Care Systems Reform (SCAN Foundation Initiative)
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What We Didn’t
• Differences in Approaches Emerged
• Participatory Workgroups Proved Difficult to
Sustain
• Most Strategies Will Take a Longer-term Effort
than the Project Will Last
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Olmstead Summit Resources
• All PowerPoint Presentations and Handouts from
the Summit, including the DEMOS
Communications Training, May Be Found at Our
Website:
www.californiansforolmstead.org under California
Olmstead Summit
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III. Key Policy Work
Hopes and prayers, the general desire to do good
without knowing how, seem to us frail reeds on
which to lean, though these are the bases on
which many programs are begun.
-Pressman and Wildavsky, Implementation,
1984
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Approaches
• Articulate a Theoretical Framework
• Utilize Policy Analysis
• Promote Long-term Care Reform
Strategies Derived from Best Practices
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Policies Imply Theories: Articulate a
Theoretical Framework
• Social Justice and Consumer-Driven Orientation
• The Ecological Systems Model is an Overall
Framework (Also described as Person-inenvironment, Whole Person, or Bio-PsychoSocial-Spiritual Approach)
• Within this, the Strengths Perspective, Wellness
Perspective, Family Theory, Culture Theory,
Empowerment Theory, Recovery Model and
Resilience Model are Useful
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Steps in Policy Analysis
-Eugene Bardach
1) Define the Problem
2) Assemble Some Evidence
3) Describe Potential Options or Interventions
(Including the DO NOTHING Alternative)
4) Select Criteria that Will Define Success
(Including Cost-effectiveness)
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Steps in Policy Analysis
-Eugene Bardach, cont’d.
5) Project the Outcomes of Each Alternative
(Including Consideration of Unintended
Consequences)
6) Confront the Trade-offs (Sometimes Called a
Cost-Benefit Analysis)
7) Decide Between Options
8) Communicate Your Analysis in Simple Terms
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Describing Potential Options:
Focus on Best Practices
• Characteristics of Effective State Long-Term
Care Systems (Washington, Oregon, Vermont)
• Considering Best Practices in a State More Like
California – Pennsylvania’s Successful Transition
Services
• Characteristics of Effective County Long-Term
Care Systems (San Francisco)
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Effective State Long-term Care
Systems
• Washington State began by defining a strong
statement of Vision and Values that guided the
development of the long-term care system.
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Washington State Vision
• Consumer choice should drive the long-term
care system.
• Quality of life is as important as quality of care.
• No one service is more important than another
– the most important service is the one the
consumer wants and needs.
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Values
•
•
Persons with disabilities and their families are
entitled to maximum feasible choice and
participation in selecting care settings and
providers.
Persons with disabilities have the right to
expect “quality of life,” personal dignity,
maximum feasible independence, health and
security.
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Values, cont’d.
•
•
People with disabilities have a right to choose
and direct a care plan involving “managed
risk,” in exchange for the advantages of
personal freedom.
The array of public service options and
individual consumer choices may be bounded
by reasonable considerations of costeffectiveness.
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Nine Critical Elements of the
Washington State Long-Term Care System
1. A strong statement of mission and values to
guide system development
2. A single organizational unit in state
government to plan, develop and operate the
long-term care system
3. Single budget with flexibility and authority to
spend on a varied array of long-term care
services
4. Process for assuring quality oversight
throughout the system
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Nine Critical Elements of the Washington State
Long-Term Care System, cont’d.
5. Strong and organized stakeholders and advocates
6. A process for resource development that meets
consumer demand
7. Fast, timely and standardized financial and
functional eligibility that generates reliable data
8. Care coordination system with capacity to provide
assistance and oversight for consumers
9. Fair rate setting and contracting process for
providers
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Recognizing Pillars To Build Upon
• A Comparison of Core Elements in 3
States with Effective Long-term Care
Systems:
– Washington
– Oregon
– Vermont
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Comparison of Core Elements
Core Element
Washington
Oregon
Vermont
Vision, Values Consistent
w/Consumer Choice
YES
YES
YES
Single Org. Unit in State
Government
YES
YES
YES
Single Budget w/Flexibility to
Spend on Array of Serv.
YES
YES
YES
Quality Assurance Process
YES
YES
YES
Strong, Organized Stakeholders
& Advocates
YES
YES
YES
Sustainable Resources to Meet
Consumer Demand (Efficiencies
+ Tax Rev)
YES, although
proving weak in
recession
NO – ONLY EFFICIENCIES
--Reason for Current
Erosion of System
NO - ONLY EFFICIENCIES
– Utilized Homecare Tax –
Erosion
Fast, Timely & Std Financial,
Functional Eligibility
YES
YES
NO – Small state, do not
have much problem w/this
Care Coordination System
w/Effective Transitions
YES
YES
YES
Fair Rate Setting and Contracting
Process
YES
YES
YES
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Effective Practices from States that
are More Like California
• Pennsylvania is a leading state in transitioning
people from nursing homes.
– It is more like California in that it has a strong
county-based system.
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Targeted initiatives
Pennsylvania’s MFP Transition Program
• In 3 ½ years, PA transitioned 1,600 persons from
nursing homes. Scaled to CA, that would be 4,600
persons per year.
• They estimate their savings to exceed over $200
million in nursing home expenditures.
• Roughly 1/3 of all transitions do not require state
funded services following transition.
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How?
• Funding: They started with a Money Follows
the Person Grant, and added General Fund
dollars. In 2008 they invested $10 million, in
2009 $14 million.
– They use the general fund dollars to provide the
most flexible program aspects. They also have a line
item in each state waiver to support transition.
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How? cont’d.
• Reimbursement Structure: They have 80
transition providers and pay them both for time
spent w/consumers as well as for benchmarks
(30,90,180, 270 and 365 days living in the
community).
• Housing: Intense collaboration at Cabinet level
between LTC and state Housing Finance Agency.
Regional housing staff co-located in transition
agencies. Preferences for people transitioning,
rental assistance, and renter’s training programs.
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Characteristics of Effective County
Long-Term Care Systems
Utilized in San Francisco, Informing in Sonoma and
San Diego
• Consumer-driven
• Single Point of Entry (allows quality assurance)
• Comprehensive Package of Services that are
Tailored to the Individual and Can Change with His
or Her Needs
• Seamless Transitions Between Care Settings
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Characteristics of Effective County
Long-Term Care Systems, cont’d.
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•
•
•
•
Package Designed on Assessment, with
Consumer Choice
Funding for Services
Array of Services
Clear Lines of Responsibility and Oversight
Flexibility to Make Changes
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System Change: The Washington State
Long-Term Care Forecasting Commission
• As a result of their effective long-term care system,
policymakers have confidence that spending these
funds does actually save the state money.
• Solid assessment data allows the Commission to
project total need for home and community-based
services.
• The Governor and the Legislature agree without
further ado to put the funding recommended by the
Forecasting Commission into the budget for HCBS.
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System Change: The Washington State
Long-Term Care Forecasting Commission,
cont’d.
• Successful policies should take advantage of the
effectiveness of statewide coordination as well as the
efficiencies of the local delivery system, and have
clearly defined state and county roles.
• There must be careful planning for these roles to be
delineated, integrated and implemented. This usually
does not happen and it is critical to successful
outcomes.
• Never underestimate the power struggle between
state and county government.
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System Change Opportunities In
Federal Healthcare Reform
• In addition to expansion of health insurance
coverage, created a long-term care framework
• CLASS Act – Long-term care insurance, no
exclusion for pre-existing conditions, 5 year
vesting period, $50 per day cash benefit to
purchase services and supports
• Community First Choice – increases Federal
share of community-based attendant services
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System Change Opportunities In
Federal Healthcare Reform, cont’d.
• Home and Community-Based Services State Plan
Option
• Expands and extends Money Follows the Person
demonstration projects
• Extends spousal impoverishment protections
• Funding of Aging and Disability Resource Centers
• Care Transitions Program
• Support for the Direct Care Workforce
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Draft California LTSS System PrinciplesAs Proposed, Not Yet Adopted
Mission Statement
• The California Collaborative advocates for the
dignity, care, maximum independence, and the
physical, mental and economic well-being of
Californians who experience disabilities,
functional impairments, and chronic conditions.
The Collaborative supports policies that prevent
people from becoming impoverished, as well as
a system of high-quality, cost-effective longterm services and supports that strengthen the
person, his or her family, and caregivers.
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Draft California LTSS System PrinciplesAs Proposed, Not Yet Adopted, cont’d.
Definition: Long-Term Services and
Supports
• Long-term services and supports refer to a wide
range of personal, medical and social/financial
assistance needed by persons with functional
limitations over an extended time. The services
may be publicly or privately financed, delivered
in a wide range of settings, and may change as
the needs of the individual who uses the
services change.
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Statement of Principles
The Collaborative Endorses a System of Long-Term Services
and Supports Based on the Following Ten Principles:
1. Dignity: The services are grounded in respect for the person
who uses them.
2. Choice: The services are driven by the preferences of the people
who use them and access to all types of services is provided on
an equal footing.
3. Flexibility: The services are comprehensive and flexible enough
to meet changing needs and incorporate new modes of service
and supports.
4. Quality: The services system values and rewards high-quality
care.
5. Legality: The services are consistent with the legal rights of
individuals who use them.
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Statement of Principles, cont’d.
6. Cultural Competence: The services are appropriate
and responsive to the needs of underserved
populations.
7. Accessibility: The services are easy to locate and use
and are physically and programmatically accessible.
8. Affordability: The services are cost-effective for the
person and the system.
9. Inclusive: The services recognize and support highquality paid and unpaid caregivers.
10. Independence: The services support maximum
independence and quality of life.
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Conclusion
Community-Based Organizations have
to become the key engine for policy
development. We must increase our
policymaking capacity to meet this
challenge.
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Thank You
Laurel Mildred, MSW
Olmstead Advocacy Director
California Foundation for Independent Living Centers
1234 H Street, Suite 100
Sacramento, CA 95814
(916) 325-1690 voice
(916) 325-1695 TDD
laurel@cfilc.org
www.californiansforolmstead.org
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CIL-NET Attribution
Support for development of this training was provided by
the U.S. Department of Education, Rehabilitation Services
Administration under grant number H132B070002-10. No
official endorsement of the Department of Education should
be inferred. Permission is granted for duplication of any
portion of this PowerPoint presentation, providing that the
following credit is given to the project: Developed as part
of the CIL-NET, a project of the IL NET, an
ILRU/NCIL/APRIL National Training and Technical
Assistance Program.
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