Enhancing Community Based Services Phase One of Massachusetts' Plan July 31, 2002 Submitted by: Executive Office of Health and Human Services Executive Office of Administration and Finance Executive Office of Elder Affairs Table of Contents I. Executive Summary 1 II. Introduction 4 III. Olmstead Advisory Group 6 IV. State Agency Planning Process 7 V. Planned Activities for Fiscal Year 2003 9 1. Education and Outreach 11 2. Identification of Individuals 12 3. Assessment and Planning for Individuals and the System 12 4. Service Coordination 13 5. Matching Service Delivery System to Identified Needs 15 1) Supported Living 15 2) Community Service Delivery 15 3) Improvement of Healthcare Services 15 4) Personal Care Attendant (PCA) Services 16 5) Employment for Persons with Disabilities 16 6) Assistive Technology 16 7) Transportation 16 8) Eligibility and Financial Issues 17 6. Housing 17 1) General Recommendations 18 2) Removing Barriers to Housing 19 3) Maximizing or Expanding the Housing Supply 19 4) Housing Utilization 20 7. System Monitoring and Evaluation 21 VI. Future Planned Growth and Work Activities 22 VII. References 26 VIII. Appendices 27 A. Committee Membership Lists B. OAG Subcommittee: Individuals Who Are Institutionalized C. OAG Subcommittee: Individuals at risk of Institutionalization D. OAG Subcommittee: Community Services and Supports E. OAG Subcommittee: Housing I. Executive Summary Overview: Since 1990, Massachusetts has shifted its focus from relying on facility-based care to developing community-based options for elders and people with disabilities. The number of Massachusetts adults receiving mental health services in state mental health facilities has declined by more than 45% since 1990. At the same time, the number of adults receiving mental health services in the community tripled. Since 1992, the number of individuals with mental retardation who reside in a facility has declined over 50%; the number of individuals receiving home and community-based services rose from 2,800 to more than 11,000. In the past 5 years, nursing facility utilization has fallen off, with Medicaid reimbursing approximately 9% fewer bed days while home and community-based waivers grew by 15% annually. As a national leader in successfully developing networks of services and supports for individuals with disabilities, Massachusetts has relied on ongoing broad-based planning activities to provide comprehensive guidance on future growth and change. Growing attention at the national, state, and local levels is focused on the needs and preferences of people with disabilities. This focus has been galvanized by the increased longevity of people with disabilities, the aging of America's baby boomers, advances in the independent living movement, and the 1999 United States Supreme Court decision Olmstead v. L.C. As the next steps in the planning and implementation process Governor Jane Swift: ? Directed members of her cabinet to develop a written plan for enhancing community-based services within the state; and ? Appointed an advisory group, known as the Olmstead Advisory Group, to provide insight and recommendations to those agencies involved in planning enhancements to the system. Process: The Olmstead Advisory Group, consisting of experts in the disability, advocacy, and legal fields, held a series of listening sessions between November 2001 and January 2002 with the assistance of state officials where nearly one thousand individuals with disabilities, their family members, providers, and advocates provided testimony on remaining barriers and suggested solutions in community living. The Olmstead Advisory Group developed four subcommittees to develop recommendations for the Interagency Leadership Team. The Executive Branch organized a Steering Committee composed of the Secretaries and Commissioners of the key human service agencies to oversee the development of a plan for enhancing community-based services. The Steering Committee designated an Interagency Leadership Team to draft the plan in consultation with the Olmstead Advisory Group. Additionally, the Steering Committee and the Interagency Leadership Team adopted a vision statement and guiding principles from which to work. Massachusetts' vision is: "to assure that Massachusetts residents with long-term support needs have access to accessible, person-centered services and community options that maximize consumer choice, direction, and dignity." Plan: To continue to make progress toward fully realizing the vision, certain additional supports and services need to be available to Massachusetts' citizens. Coupling the recommendations provided by the Olmstead Advisory Group with the vision and guiding principles, the Interagency Leadership Team divided its strategic activities into seven areas. They include: ? Education and Outreach; ? Identification of Individuals; ? Assessment and Planning; ? Service Coordination; ? Matching Services to Individual Needs; ? Housing; and ? System Monitoring and Evaluation. The state agencies drawing upon recommendations from the Olmstead Advisory Group set out the strategic activities in Expanding Community-Based Services: Phase One of Massachusetts' Plan. The activities are grounded in the concepts that services should respond to the needs and preferences of individuals, that specific steps may be taken immediately to strengthen Massachusetts' commitment to people with disabilities, and that certain complex system functions or gaps will require careful and deliberate analysis in order to effect necessary systemic changes. Proposed analyses include a universal information and referral database; transition assistance services; supports for family care giving; and sustainable financing methods; these analyses are designed to assure that the state can move deliberately to implement effective practices. Highlights of Phase One activities include: ? Continuing to target for community placement individuals for whom community placement is desired and available; ? Educating individuals residing in facilities, as well as their families and support systems, about the array of community-based services available, residential options available, their eligibility status for those services, and then documenting the individual's preferences; ? Identifying and capturing information related to individuals with disabilities who reside in public facilities and could relocate safely to the community and either provide or document the absence of necessary services and supports; ? Require that all state agencies offering long-term care pre-screen Medicaid eligible beneficiaries seeking facility-based services for the possibility of community-based care; ? Designing and implementing pilot projects to evaluate different models of service coordination for community-based individuals and individuals wishing to leave a facility; ? Completing the implementation of new income disregards in determining MassHealth eligibility for personal care attendant (PCA) services to include people aged 65 or greater; ? Identifying improvements to expedite the approval of medical equipment, assistive technology, and PCA services prior approvals; and ? Improving the availability of accessible and affordable housing throughout the state. Implementation of Phase One activities will begin in August of 2002. The activities will be implemented using existing resources, including current appropriations and the Real Choice Systems Change, Nursing Home Transition, and Medicaid Infrastructure grants. Future Planned Growth and Work Activities: In consultation with the Olmstead Advisory Group, the Interagency Leadership Team will: ? Continue to provide leadership and policy direction as planned activities are implemented; ? Establish a Real Choice Consumer Task Force to provide advice on specific issues related to project implementation; and ? Continue to review recommendations of the Olmstead Advisory Group to identify which activities will be included in Phase Two of the Plan, to be developed by January 1, 2003. II. Introduction Massachusetts has been a national leader in developing and enhancing community-based services for people with disabilities. Through the Medicaid state plan, Medicaid home and community-based services waivers, and many other state and federal programs, the Commonwealth has developed a wide variety of options to help people with all types of disabilities of all ages to live and work in the community. Over the past several years, Massachusetts has focused its efforts on creating community-based options for elders and people with disabilities. While Phase Two of this plan will outline those efforts in more detail, the following are some examples: ? In 1990, more than 1,850 Massachusetts adults received mental health services in state mental health facilities. Today, that number has shrunk to less than 1,000 people, a decline of more than 45%. During the same period, the number of adults with a mental illness who received residential services in the community almost tripled, climbing from 2,500 to more than 7,200 individuals. ? Since FY92, the number of individuals with mental retardation who reside in a state facility has declined over 50%, from 2,643 to 1,235. Within an expanded home and community-based services waiver, the number of individuals with mental retardation who receive services almost tripled, rising from 2,800 to more than 11,000 consumers. The number of individuals with mental retardation and their families receiving community support services expanded from 21,000 in FY92 to 30,772 in FY01, which represents growth of over 45%. ? Despite the growth in the elder population, in the past five years utilization of nursing facilities by older people and individuals with disabilities has decreased slightly. The number of nursing facility days paid for by Medicaid has decreased by approximately 9%, representing fewer people and shorter lengths of stay. In keeping with this trend, the number of licensed nursing facility beds has dropped by 3,477 beds from January 2000 to June 2002 while the nursing facility occupancy rate has dropped to 91% on average across the state. ? From 1996-2000, Home and Community-Based Services Waiver expenditures for frail elders and individuals with mental retardation grew approximately 15% per year. Medicaid community-based State Plan expenditures have increased by 21% during each of the last two years. The Medicaid community-based State Plan services represented 19% of the Medicaid budget in FY98 and have increased to 24% in the past fiscal year. ? Since the fall of 2001, the Massachusetts Family Caregiver Support Program has been implemented, providing community services and supports to over 36,000 caregivers of elders or elderly caregivers of children, delaying and potentially even preventing facility placement. In this six month time period, a number of new community service options have been created, including the provision of case management services to 2,120 caregivers, expanded hours at some adult day health care programs for 107 elders, and the expansion of a consumer directed care pilot that has allowed approximately 120 elders to hire, supervise, and fire their own personal care workers. ? In the four years since the Supportive Housing Program began, over 4,000 residents of elder public housing in twenty-two communities have received "assisted-living-like" services in their own homes. ? In 2000, Massachusetts was the only Vocational Rehabilitation agency in the country to receive a Department of Transportation grant to address the lack of accessible transportation for people with disabilities. ? Care coordination and family support services to children with special health needs increased by 28% and 36% respectively over the past five years, and service coordination was provided to over 600 adults with multiple sclerosis during the past two years. ? Massachusetts' emphasis on providing community-based employment services with a focus on consumer choice and performance outcomes has resulted in 1,548 individuals with disabilities, who were either unemployed or in sheltered settings, moving to competitive employment in the past three years. In 2000-2001, Massachusetts began a pilot project to provide assistive technology to individuals with disabilities and allow independent living goals such as banking, shopping, and communicating. The program now serves three hundred people annually. Long-range planning has been a key component in the development of responsive systems of service and support. Recent examples of such planning are documented in A Preliminary Report: Alternatives for Improving Private Financing of Long-Term Care in Massachusetts (November, 1996); Status of the Elderly in Massachusetts: A Statewide Survey Report (1993); Background Paper on Long-Term Care in Massachusetts: Prepared for the Vision 2020 Task Force (April, 2000); Health Care Finance Report on Long-Term Care (June, 2001); and Executive Order # 421: Report on Long-Term Care (August, 2001). In June 1999, the Supreme Court rendered a decision that created an additional impetus for planning related to community-based services in a case that has come to be known as the Olmstead decision. The ruling required states to provide community-based services for people with disabilities in facilities when: ? The state's treatment professionals have determined that community placement is appropriate; ? The transfer from care to a less restrictive setting is not opposed by the affected individual; and ? The placement can be reasonably accommodated, taking into account the resources available to the state and the needs of others. As part of the Olmstead ruling, the Supreme Court provided an example of how a state could show that it had met the standard for "reasonable accommodation" by demonstrating that it had: ? "A comprehensive, effectively working plan" for placing people with disabilities in less restrictive settings; and ? "A waiting list that moved at a reasonable pace" not controlled by the state's attempts to keep its facilities full. Although the Olmstead decision did not mandate any specific planning process, the Commonwealth's planning processes have both preceded and followed the Court's ruling. This current plan for enhancing community-based services builds upon prior accomplishments and the previous planning activities to bring together the work of the key human service agencies and advocates involved in working with people with disabilities. The plan identifies the next steps for continuing to assist individuals who are in facilities to move to more integrated settings and to assist individuals who are at risk of entering facilities to remain in the community. III. Olmstead Advisory Group To assure that planning efforts had been sufficiently comprehensive, in July 2001 Governor Swift established an Olmstead Advisory Group to provide an opportunity for people with disabilities to give recommendations about ways to improve opportunities for community living. At the same time, the Governor directed the Executive Branch to develop a comprehensive plan for enhancing community-based services. The Olmstead Advisory Group included a panel of experts in the disability, advocacy, and legal fields. State agency representatives participated in the meetings as ex officio advisors. The Olmstead Advisory Group convened a series of five listening sessions between November 2001 and January 2002, enabling nearly a thousand people with disabilities, providers, family members, and advocates to give testimony about the barriers to community living and possible solutions. During this time, the Olmstead Advisory Group developed four working subcommittees: ? Individuals in Institutions; ? Individuals At Risk of Institutionalization; ? Community Services and Supports; and ? Housing. The subcommittees were comprised of individuals with background in the subject matter, and were not limited in membership to members of the Olmstead Advisory Group. They met regularly during the winter to discuss common themes brought up during the hearings and to develop the themes into a set of specific recommendations. The recommendations of the Olmstead Advisory Group expressed a belief that the Commonwealth should shift the proportion of state resources devoted to long-term care from facility-based to community-based services and make nursing and other facilities a last resort for people with disabilities of all ages. The Olmstead Advisory Group recommended that services be tailored to the needs of individuals rather than the availability of providers. The group also advised that funding for flexible, individualized, community supports should be available to enable individuals to move from facilities into the community. In making these recommendations, the Olmstead Advisory Group expressed a belief that availability of flexible resources would generate the demand for community- based supports, which would in turn lead service providers to organize themselves to accommodate the demand. IV. State Agency Planning Process The Executive Branch organized a Steering Committee and an Interagency Leadership Team to develop the state's plan for enhancing community-based services. Members of the Steering Committee included the Secretaries and/or Commissioners from the Executive Office of Administration and Finance (EOAF); the Executive Office of Elder Affairs; the Executive Office of Health and Human Services (EOHHS), including the Division of Medical Assistance (DMA), the Massachusetts Rehabilitation Commission (MRC), and the Departments of Public Health (DPH), Mental Health (DMH), and Mental Retardation (DMR); and the Department of Housing and Community Development (DHCD). Members of the Interagency Leadership Team included designees of the Secretaries and/or Commissioners from those agencies. (Refer to Appendix A for lists of agencies and members participating in the Steering Committee, the Interagency Leadership Team, and the Olmstead Advisory Group.) Staff assistance in facilitating meetings and preparing draft documents was provided by the Center for Health Policy and Research (CHPR) at the University of Massachusetts Medical School (UMMS). The Steering Committee and Interagency Leadership Team decided that an important step in creating a plan for enhancing community-based services was to develop a common vision and set of guiding principles. The Interagency Leadership Team reviewed examples from other states and from previous state planning processes and developed the following vision which was adopted by the Steering Committee: To assure that Massachusetts residents with long-term support needs have access to accessible, person-centered services and community options that maximize consumer choice, direction, and dignity. From the vision, a set of guiding principles naturally flowed. Many of these principles had been developed previously and set forth in the Commonwealth's Executive Order # 421: Report on Long-Term Care (August, 2001). Guiding Principles for Long-Term Care Planning ? Provide the needed information, services, and service coordination to allow informed consumer choice of available options; ? Honor the preferences of elders and persons with disabilities to remain in the community whenever possible; ? Improve the balance of spending between community-based and facility- based care so that expanded options for community living can be made available; ? Assist individuals in transitioning from facilities to the community; ? Improve access to and quality of health care for people with disabilities; ? Ensure that services are accessible to all people including individuals from culturally and linguistically diverse populations; ? Evaluate service and program efficacy using systematic data collection and analysis; and ? Modify the culture of facilities to reflect community life, options, and values more fully. V. Planned Activities for Fiscal Year 2003 The Interagency Leadership Team reviewed the recommendations of the Olmstead Advisory Group to determine which activities were consistent with the vision, guiding principles, and specific priorities of each agency. All subcommittee reports were examined in detail and there was general agreement with the philosophy and approaches recommended. The Interagency Leadership Team then identified activities that could be initiated within FY03 using existing state funds or federal funding (including funding under the systems change initiative) and forwarded the list for review and approval by the Steering Committee. Enhancing Community-based Services: Phase One of Massachusetts' Plan is intended to be a work-in-progress. Phase One will be followed by an update after the first six months and an update periodically thereafter. The Interagency Leadership Team recognized that the Governor's Olmstead Advisory Group proposed many recommendations. The complete set of recommendations is included in the four subcommittee reports in Appendices B through E. Not all of the recommendations could be initiated in the short term. The planned activities below represent a subset of the Olmstead Advisory Group recommendations. However, the final section of this plan provides the next steps for considering the recommendations of the subcommittees not initiated in Phase One. In order to assure that a variety of community-based living arrangements and supports are available, certain services and supports need to be developed. The Interagency Leadership Team divided its strategic activities into seven functional areas to reflect the necessary components of an effectively functioning system. These seven areas are: ? Education and Outreach: to assure that individuals and their families have adequate and necessary information to make informed choices; ? Identification of Individuals: to identify individuals in facilities or at risk of entering facilities in order to assist them in considering appropriate alternatives; ? Assessment and Planning: to identify the abilities, preferences, and needs of individuals and assist them in locating appropriate supports and services; ? Service Coordination: to offer assistance in arranging and coordinating services for those who are unable to manage arrangements on their own; ? Matching Services to Individual Needs: to develop and refine a delivery system in which eligible consumers can choose from an array of services and supports tailored to their needs and preferences; ? Housing: to enhance the availability, affordability, and accessibility of housing to enable individuals to live in the community; and ? System Monitoring and Evaluation: to ensure that the system of services and supports is continually evolving and responding efficiently and effectively to consumers. This plan includes 62 activities to be implemented in FY03. Over two-thirds of the planned activities are specific actions to adapt the system to allow it to be increasingly responsive to consumers' needs. In addition, the plan identifies complex system functions or gaps that will require careful analysis in order to create necessary systemic changes. These functions include a universal information and referral database, transition assistance services, supports for family caregiving, and sustainable financing methods. The proposed studies and analyses related to these and other activities are designed to assure that the state can move to implement effective practices that fundamentally change the service system. 1. Education and Outreach An important component of identifying and providing community choice to individuals in facilities and those at risk of placement in facilities is the provision of sufficient information to enable individuals and their families to make informed choices. Such education should involve general community information and specific education of persons with disabilities and their families. Planned Activities A. Expand and/or develop provider training designed to promote consumer involvement and independence. The training teams should include consumers and family members and should offer training to providers and individual health care practitioners by: ? Working collaboratively with families, including families of minors. This includes recognizing the role of parents as the 24/7 caregivers and providing skills training to professionals to help them work with and offer training to parents that will promote the practice of family collaboration and partnering with parents as equals; ? Providing accessible services and/or programs, which include consideration of physical, communication, linguistic, and cultural access; and ? Understanding principles of consumer direction and how this can enhance the relationship between individuals and their providers. B. Expand and/or develop a process to educate individuals residing in facilities and/or their guardians about the array of community and residential options. Such education might include, but is not limited to: ? Providing an informational booklet explaining integrated community-based services, and the various planned options and remedies available; ? Reviewing informational materials with the individual (and/or guardian); and ? Developing or maintaining a process to insure individuals residing in facilities are informed of their service eligibility status and residential options, and then documenting their preferences for services. C. Begin to facilitate informational sessions that provide opportunities for gathering input from consumers and their families regarding barriers and solutions to accessing health care and other services in the community. This could include holding diverse focus groups to elicit feedback on the role of the family versus the role of the state in the provision of care to elders and younger persons with disabilities. Agencies will then review for implementation of appropriate actions as resources allow; and D. Look at information technology in order to develop or build upon current systems such as the Massachusetts Network of Information Providers (MNIP), 800-AGE-INFO, MassCares, Elder Affairs Systems Environment (EASE) (in development), and others in order to create a common or universal information and referral database. 2. Identification of Individuals A flexible community support system will help to assure that there are adequate, viable alternatives to placement in a facility, particularly for those who are not currently served by the system in a desirable coordinated fashion. Therefore, an important step in planning is to determine who is in a facility or at risk of placement in a facility, and the number of persons who are interested in receiving services in more integrated settings appropriate to their needs. Planned Activities Analyze the current client populations in facilities or at risk for facility placement utilizing Medicare and other data sets. Such analysis should include establishing a database categorized by type of disability, facility placement/location, and funding source to identify: ? The number of individuals with disabilities who reside in public facilities who could be relocated to the community if there were adequate family supports and if reallocation of existing state funds would be adequate to support services needed to live safely in the community; and ? The number of individuals with disabilities who are at risk of entering a facility if appropriate services and supports are not available. 3. Assessment and Planning for Individuals and the System Assuring that all individuals with disabilities are presented with their options for community care may involve some redesign of current intake features in existing state agencies. A consistent process for screening and assessment of individuals with disabilities of any age, for long-term care services, would provide such assurance. Planned Activities A. Begin the development of a single screening and assessment process with specialized modules to be used to assess all people with disabilities seeking publicly funded long-term services, regardless of where they presently reside or their risk status. The process should be designed to facilitate diversion and community reintegration through comprehensive service planning and communication between different state agencies and providers. The components of the assessment process shall include at a minimum: ? Identification of the assessment team and their qualifications; ? Identification of such factors as the array of services an individual needs, the types of services that could be provided in the community, and any reasonable accommodations that might be required to enable the individuals to benefit from particular services; ? Identification of the specific interests, goals, likes, and dislikes of the individual; ? An evaluation of the individual's functional limitations, living arrangements, support systems, medical issues, financial resources, and the risk of abuse, neglect, or exploitation; ? Involvement of any family, friends, or advocates chosen by the individual (or guardian) to be present; and ? Assessment of the assistive technology needs of individuals with disabilities that are moving into the community. B. Require that all state agencies offering long-term care pre-screen for appropriateness of community care all individuals eligible for Medicaid who are seeking facility-based services. A rule out of community services should be a part of such screening with diversion the primary goal; and C. Maximize opportunities for inter- and intra-agency efforts to collaborate, coordinate, and streamline service delivery to people with disabilities by identifying current activities and resources across agencies as they relate to the FY03 ECBS plan. 4. Service Coordination Models of individual support are labeled differently by different agencies (supported living, case management, assertive community treatment, etc.). Regardless of the label, individualized support should include some type of service coordination to assist people in areas of daily living that they cannot manage independently. Planned Activities A. Evaluate effectiveness of existing service coordination systems and design and implement pilots to improve specific elements of service coordination both for those in the community and those who are transitioning. Agencies with systems in place will collaboratively share knowledge with other agencies; B. Identify state agencies that have caregiver support programs, assess them for best practices, and improve interagency collaboration and service coordination to more effectively and efficiently serve aging family caregivers; C. Develop a discharge service plan checklist for persons with disabilities and consider incorporating at least the following components: ? Rent subsidies; ? Housing search assistance (where the subsidy is a tenant-based voucher) including access to security deposit and move-in funds; ? Tenant stabilization; ? Adequate and appropriate support services; ? Vocational services; ? Accommodation plans for tenants who may need temporary hospitalization or nursing facility placements to insure no loss of housing; and ? Respite and other family supports for individuals returning to a family setting. D. Explore ways to improve how agencies and programs provide transition assistance to people leaving facilities for community-based services, such as: ? Ensuring a smooth transition from facilities to community-based services by providing funding for one-time transition costs such as initial security deposit and first month's rent for community-based housing, and assessing and making modifications to homes and vehicles prior to the persons move from the facility; ? Allowing each individual pre-placement home visits and overnights; ? Enabling each individual to request pre-service training for community support staff (prior to actual placement) based on individual service needs; ? Assuring that an Individualized Education Plan (IEP) and/or Individual Transition Plan (ITP) is part of the discharge plan for school-aged individuals prior to moving from a facility into the community; and ? Researching how the Centers for Medicare and Medicaid Services (CMS) can further support the transition process through Medicaid waivers or matching funds for one-time costs associated with setting up housing. 5. Matching Service Delivery System to Identified Needs Massachusetts supports the belief that all individuals with disabilities should have opportunities to live, work, enjoy leisure, receive treatment, and achieve rehabilitation in the available settings of their choice. Thus, Massachusetts will continue to develop and offer services in normative community settings that strive to offer a full range of choices to people with disabilities, wherever available. The state will dedicate existing and new resources to the development of a wide spectrum of residential and other support services in the community. These services will be provided through a variety of models including 24-hour on- site staff supervision, supported housing, and in-home assistance for people living on their own. Because this section includes diverse models and options, it is further divided into subsections. Planned Activities 1) Supported Living Look at the range of supported living models in order to study and report on situations in which housing and services are linked, explore the reasons for those linkages, and identify situations in which services may be better provided when de-linked from housing. 2) Community Service Delivery A. Continue to target (for community placement) persons for whom community placement is appropriate and available; B. Explore alternative models of service delivery and the financing for those models; C. Conduct a study to evaluate the impact of establishing new options or expanding existing options within state agencies that allow family and non- professionals to serve as paid caregivers to individuals with disabilities of any age qualifying for long-term care services in the Commonwealth, and explore other forms of compensation. This study will examine both national and Massachusetts models and may lead to the development of a pilot program; and D. Review best practices across the nation for offering compensation and benefits to community direct care workers. 3) Improvement of Healthcare Services A. Improve and support community programs providing preventive health care services; and B. Improve and support community programs providing substance abuse, diversionary health, and mental health care services. 4) Personal Care Attendant (PCA) Services A. Complete the implementation of new income disregards in determining MassHealth eligibility for PCA services to include people over the age of 65; B. Review criteria for what constitutes an acceptable timeframe for prior approvals for PCA services; and C. Review PCA reimbursement rates in accordance with the current Department of Health Care Finance and Policy (DHCFP) requirements. 5) Employment for Persons with Disabilities A. Continue efforts to ensure equal access to all employment services at One- Stop centers and their mandated partners such as Public Vocational Rehabilitation at Massachusetts Rehabilitation Commission (MRC) and Massachusetts Commission for the Blind (MCB) as well as other disability agencies; B. Develop closer coordination between the activities under the ECBS plan and the Medicaid Infrastructure Grant; and C. Coordinate all employment-related services utilizing the Employment Services Action Council (ESAC) and newly developed grants network. 6) Assistive Technology A. Examine pre-approval systems, including timeframes and criteria, and suggest improvements to expedite the approval of medical equipment, assistive technology, and home modifications needed in order to allow people to move out of facilities or otherwise help them remain independent in their own homes; and B. Identify, coordinate, and maximize resources of agency assistive technology programs already in place within the Secretariats. 7) Transportation The Interagency Leadership team shall engage and support the Executive Office of Transportation in continuing and/or beginning to address the following transportation initiatives: ? Develop a plan to bring all state-funded fixed-route service (including bus, subway, and ferry service) into compliance with ADA access requirements; ? Conduct a comprehensive review of paratransit services run by the MBTA and the RTA's to insure that they are operated in compliance with ADA eligibility requirements; ? Conduct a comprehensive review of human service transportation programs by the state, including elderly services, to increase coordination and eliminate duplication; and ? Conduct a comprehensive analysis of current public transportation and/or transportation options across the state to determine where gaps and overlap in transportation services exist in order to create and enhance interregional transit equity, comparability, and reciprocity. 8) Eligibility and Financial Issues A. Conduct a comprehensive study or studies, which could include the convening of a workgroup, to identify the implications of DMA eligibility policy on non-working disabled adults. The focus will be on the impact of current income eligibility policy; for example, having variant income spend-down policies across several different member groups covered under MassHealth; B. Identify and report on the costs, benefits, and feasibility of implementing a Home and Community-based Services (HCBS) waiver for those not currently covered by existing HCBS waivers (for example, members who have disabilities, who are under age 65, and who are not currently eligible under any HCBS waiver); and C. Continue discussions with the DMA on the use of Medicaid waivers, delivery options, and support services that keep elders out of facility settings, including the Community Choices Initiative, Senior Care Organizations (SCO), and federal reimbursement under Title XIX (through Centers for Medicare and Medicaid Services) for one-time housing costs associated with transferring from an institutional facility into a community setting. 6. Housing An adequate supply of affordable and accessible housing must exist to insure that people with disabilities who are leaving facility settings or who are at risk of going into a facility have an acceptable place to live. The Commonwealth will continue to create incentives to increase the supply of housing and maximize the existing housing resources in order to expand community-based housing options for people with disabilities. Below are guiding principles and planned activities intended to address the need for housing for people with disabilities. Community Integration: Housing for people with disabilities should be designed to integrate people with disabilities into the community as fully as possible. Accessibility: All housing for people with disabilities must be accessible. The Commonwealth will seek to promote maximum accessibility in all publicly funded housing, and therefore, improve access to integrated housing in all communities for persons with disabilities. Housing Choices: Persons with disabilities will have a variety of choices in types of housing and geographic locations. Information about housing choices must be made readily available to individuals and they must be fully informed of the housing options and the associated responsibilities (for example, lease or mortgage obligations). Community Planning: It is important that systems and supports are in place to insure that persons with disabilities can live independently wherever they choose. The state should establish a community planning and development process that includes input from persons with disabilities to create a plan that identifies housing opportunities for residents in all neighborhoods of the community. Furthermore, concerted efforts should be made to improve relationships between housing and service providers and offer incentives for housing providers to deliver units for persons with disabilities. Tenant Support Services: Adequate and appropriate services should be available as needed and chosen by the tenant to insure their successful tenancy in the community and to promote independence. In the most integrated, least restrictive housing environment, support services should be available when necessary to help insure a successful tenancy and lease compliance. Additional housing and supportive services, including tenant supports, are needed in order to insure people with disabilities are not unjustly or unnecessarily placed in a facility. Flexible and Sustainable Housing: Working together, the state housing and human services agencies should look at successful programs as models and develop "Best Practices" in order to insure that new housing is developed using a flexible and sustainable model. Support for Transitioning Individuals: If a person moves from a facility to a community setting, there is a time period in which exceptional costs and support may be required. These can include startup money, moving expenses, and first month's payment. Homes frequently must be modified. Other kinds of temporary, one-time payments must be addressed. Planned Activities 1) General Recommendations A. For projects financed or funded by the Department of Housing and Community Development (DHCD) and MassHousing, insure assisted living developments for elders and/or people with mobility disabilities are physically accessible; B. DHCD and MassHousing will explore what would be necessary in order to include universal design in new units that they fund or finance; C. Maximize occupancy in accessible units occupied by persons who need those design features by requiring use-of-lease addendums in publicly-funded housing that allows the manager to move non-disabled households from accessible units to other available apartments as needed to accommodate persons with disabilities. This in no way, however, will be interpreted as a manager's right or requirement to do so if no acceptable alternative living situation can be offered to those living in the accessible unit; D. Explore ways to improve the housing development system for people with disabilities. This could include improving relationships between housing and service providers and developing incentives for housing providers to deliver units for these groups; and E. Develop new housing, to the greatest degree possible, in areas served by regularly scheduled and accessible public transportation or in areas where fundamental services and amenities (shopping and businesses) are in pedestrian walking distance in order to prevent isolation and undue dependence on service providers. 2) Removing Barriers to Housing A. Increase public awareness of the availability of local tax abatements and deferrals to help keep elders and people with disabilities in their homes; B. Commit to a public education effort in coordination with housing and disability agencies and service providers to combat the "Not In My Back Yard" (NIMBY) syndrome. Enlist the support and resources of the Department of Housing and Urban Development (HUD) Fair Housing Division and the Attorney General's Offices of Public Protection and Disability Rights in enforcing C.151B where communities continue to discriminate against people with disabilities; and C. Advocate for continued funding of programs such as the Housing Opportunities Program's Housing Search, the Massachusetts Rehabilitation Commission (MRC) Housing Registry, MRC Home Loan, and the Tenancy Preservation Program. 3) Maximizing or Expanding the Housing Supply A. Consider ways to increase the number of units in assisted living developments available to low-income individuals; B. Subject to available funding and programmatic feasibility, insure all existing publicly financed housing has completed Section 504/ADA self-evaluations and implemented transition plans; C. Expand the Department of Housing and Community Development (DHCD) definition of "homeless" beyond persons living in nursing facilities to include those living in rest homes, rehabilitation facilities, and other facilities (not including group homes operated by other agencies such as Department of Mental Retardation (DMR), Department of Mental Health (DMH), and the Department of Public Health (DPH)). Revisit the notification and public education effort with local housing authorities and other housing providers receiving state funds to insure that other individuals within facility settings may receive this preference; D. Explore approaches to streamline the process for development of affordable housing. The Affordable Housing Trust model represents a successful example of agency collaboration and efficient review process, which agencies should seek to replicate wherever possible; E. Work with the Department of Housing and Urban Development (HUD) and federal legislators to change federal statutes and regulations for project- based Housing Choice Vouchers. Changing federal statute to allow owners/service providers to identify eligible applicants and maintain the waiting list for project-based units would allow housing with services to be appropriately matched to persons with disabilities; and F. Support MassHousing's efforts to have HUD refinance 202 developments in order to both refinance mortgages and obtain additional support services funds for the developments. 4) Housing Utilization A. Department of Housing and Community Development (DHCD) and service agencies will work together to insure that Project Based Section 8 resources are utilized and allocated to best serve the needs and preferences of persons with disabilities, including developing integrated models of housing as an option; B. DHCD, MassHousing, and other public entities should conduct utilization reviews and generate recommendations for increasing utilization of resources. Ensure targeted resources such as AHVP and targeted Section 8 programs are fully used. DHCD should continue to apply for various Section 8 programs and maximize the vouchers available to people with disabilities; C. Review and evaluate the C689/67 program in light of the changing needs of persons with disabilities and the growth of the not-for-profit housing delivery system. DHCD will convene a working group consisting of all relevant parties to undertake this review and make necessary recommendations for amending the program in response to current client needs; D. Research whether underutilized housing developments for elders and persons with disabilities can be reconfigured or reconstructed to provide larger, more usable and desirable housing units. Pursue sources of funding, including working with the Department of Housing and Urban Development (HUD) and federal legislators to authorize use of federal Section 202 funds by local housing authorities for reconfiguration; E. Promote collaboration between housing and service providers. Develop ways to assist service and housing providers, for example, Aging Service Access Points (ASAP), Local Housing Authorities (LHA), and community-based human service vendors, to work creatively together with existing local resources. Housing and service agencies should continue aggressive efforts to develop partnerships of qualified providers and engage in initiatives to promote the creation of different kinds of housing models for persons with disabilities and elders, particularly units integrated in new or existing developments available to the general public; and F. Revisit housing and service programs to identify places where innovative and creative funding opportunities can be implemented within the context of existing laws and regulations. Consider modifications to laws and regulations as appropriate to allow for greater flexibility and targeted resources for this development initiative. State agencies should conduct this review. In particular, Elder Affairs' Supportive Housing model should be reviewed. 7. System Monitoring and Evaluation Developing systems to help the Commonwealth monitor and evaluate its progress will help to promote healthy living and community inclusion across the lifespan for people with disabilities. Planned Activities A. In FY03, establish a baseline of expenditure and utilization rates for facility based services that will be updated annually to serve as the basis for high- level discussion for the purposes of policy formation; B. Develop or maintain a process and timeline to examine data and compile lists of those individuals currently waiting for long-term care services from state agencies to determine unmet needs and essential services to enable them to remain in the community; C. Develop or maintain a process and timeline for analyzing state agencies current client populations to identify individuals at risk of facility placement; D. Continue to examine best practices in facility based and community care models, including those in other states that provide consistent accountability, responsiveness, and financial security, in order to identify positive elements that could be transferred to existing community care; E. Analyze data from the Nursing Facility Transition Grant and other relevant data sources to determine what community services are needed to assist individuals in successfully transitioning to the community, what needs may not be met, and what are the characteristics of successful community transitions; F. For purposes of diversion, develop a process and timeline to educate those service providers that make referrals to facilities to assist in the identification of individuals at risk for facility placement and identification of community placement alternatives; and G. Begin inclusion of disability data as a variable to determine prevalence of disability in public health surveys and programs. VI. Future Planned Growth and Work Activities Many other activities related to enhancing community-based services are underway at the various state agencies. Due to time constraints, it was not possible to include all activities in this plan. Additional agency activities will be identified and detailed during the first three months after the release of this first phase of the plan. Given the anticipated state budget for FY03 and Massachusetts enduring commitment to enhancing its systems of community-based services and supports, The Interagency Leadership Team believes the budget will support plans to: ? Add 650 community-based beds for people with mental retardation or developmental disabilities; ? Discharge 74 individuals currently receiving inpatient mental health services from Medfield State Hospital to newly created residential services in the Commonwealth; ? Close Medfield State Hospital; ? Discharge 83 adults who are currently inpatients in Department of Mental Health (DMH) facilities other than Medfield State Hospital to newly created community residential services in the Commonwealth; ? Establish 6 new Programs of Assertive Community Treatment (PACT), multi-disciplinary teams which provide needed treatment, rehabilitation, and support services to individuals with severe and persistent mental illnesses to enable them to live in the community and avoid inpatient treatment; ? Increase Statewide Head Injury Program's (SHIP) bed capacity by 5%; and ? Provide approximately 450 elders enrolled in the Home and Community- Based Services Waiver with expanded community services through the implementation of the Community Choices Initiative, in order to either prevent or delay facility placement or to allow an individual to be discharged from a facility who would not otherwise be able to do so. As noted above, the activities discussed in this plan represent next steps for which there was consensus among the state agencies that implementation could begin during FY03. They will be initiated using existing resources or by using federal funding, including but not limited to funds for systems change under the state's Real Choices, Nursing Home Transition, and the Medicaid Infrastructure grants. After release of the ECBS Phase I Plan, the following timeline will provide a basic structure to insure timely ECBS project accomplishments. Within one month: ? The Interagency Leadership Team will identify lead and collaborating agencies for ECBS planned activities; ? The Interagency Leadership Team, in consultation with the Olmstead Advisory Group, will determine the priorities for funding of Real Choice pilot projects; and ? The Interagency Leadership Team, in consultation with the Olmstead Advisory Group, will identify 15 members (at least 8 of whom are consumers) for the Real Choice Consumer Task Force to provide practical advice on Real Choice pilot projects. Within two months: ? The Interagency Leadership Team, in consultation with the Olmstead Advisory Group, will identify potential pilot projects to be developed using the Real Choice funding. ? The state agencies will complete work plans with timelines for Phase I planned activities and the Interagency Leadership Team will provide a forum for coordination and communication. ? The first meeting of the Real Choice Consumer Task Force will be held. Design and implementation of the pilot projects will begin immediately thereafter. Within three months: ? Current agency activities to enhance community-based services, which were not included in the first phase of the plan, will be incorporated in the planning document. ? The Interagency Leadership Team will carefully consider each recommendation of the Olmstead Advisory Group that was not included in the first phase of the plan and will identify which recommendations can be prioritized in the second phase of the plan. ? Massachusetts Commission for the Blind (MCB), Massachusetts Commission for the Deaf and Hard of Hearing (MCDHH), Department of Mental Health (DMH), Department of Mental Retardation (DMR), Department of Public Health (DPH), Division of Medical Assistance (DMA), and the Massachusetts Rehabilitation Commission (MRC) will complete an assessment of their current service delivery system for individual and family supports for persons with disabilities or chronic illnesses and their families. Within six months: ? The Interagency Leadership Team, in consultation with the Olmstead Advisory Group, will review Phase I of the plan and develop a second phase of the plan that will be released in January 2003. (Phase II of the Plan will be reviewed and updated by January 2004, and any outstanding recommendations from the Olmstead Advisory Group or any new recommendations will be considered at that time). The state will continue to implement two federally funded systems change initiatives: ? The "Massachusetts Bridges to Community" project, established under the Nursing Home Transition grant, will establish interagency, interdisciplinary, cross-disability case management teams to assist individuals in transitioning from nursing facilities to the greater Worcester, Massachusetts communities. Community development, person-centered advocacy, and peer mentoring will be key features of the project. ? The Massachusetts Medicaid Infrastructure grant, with guidance from the Consumer Advocacy and Advisory Panel, the Professional Advisory Group on Employment, and the Interagency Advisory Group, will implement information and referral services to assist people with disabilities to gain or maintain competitive employment. ? Budget proposals for completion of activities initiated in Phase I of the plan and new activities proposed in Phase II of the plan will be submitted for consideration as part of the FY04 House I budget process. The Executive Branch of the Commonwealth of Massachusetts is committed to implementing this planning process, the goal of which is to effectively assist individuals with disabilities to live in settings appropriate to their needs. With ongoing input from the Interagency Leadership Team, the Olmstead Advisory Group, the Real Choice Consumer Task Force, and the general public, the Commonwealth will continue to make progress in enhancing community-based services for people with all types of disabilities. VII. References Bruce, E. A. and Schulman-Green, D. (April, 2000). "Background Paper on Long-Term Care in Massachusetts: Prepared for the Vision 2020 Task Force." University of Massachusetts, Gerontology Institute. "Executive Order #421: Report on Long-Term Care." (August, 2001). Commonwealth of Massachusetts. "Preliminary Report: Alternatives for Improving Private Financing of Long-Term Care in Massachusetts." (November, 1996). Commonwealth of Massachusetts. "Report on Long-term Care." (June, 2001). Health Care Finance Working Group, Commonwealth of Massachusetts. "Status of the Elderly in Massachusetts: A Statewide Survey Report." (1993). Massachusetts Executive Office of Elder Affairs. VIII. Appendices Appendices are available upon request. For the purpose of this plan, "facilities" refers to nursing facilities, intermediate care facilities for persons with mental retardation, state psychiatric facilities, and chronic hospitals. Enhancing Community-based Services Phase One of Massachusetts' Plan 12 Phase One of Massachusetts' Plan