FSSA - DDRS: Community-Integrated Personal Assistance Services and Supports Grant

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Governor Mitch Daniels

Community-Integrated Personal Assistance Services and Supports Grant - Narrative

Identification of Problems or System Issues

Background and Identification of Problems:

The State of Indiana plans to create an enduring systems change with a packaged submission of three applications. These include (1) Real Systems Choice; (2) Nursing Facility Transition; and (3) Community-Integrated Personal Assistance Services and Supports Grant. The State, through the Family and Social Services Administration (FSSA) intends to use the majority of the grant funds under the Community-Integrated Personal Assistance Services and Supports grant to plan, develop, and evaluate an infrastructure for consumer directed attendant care. This will provide the information to amend Indiana’s six approved Medicaid Home and Community-Based Services Waivers to include consumer directed personal assistance services. During years two and three of the grant, these services will be provided to persons through the amended Waivers. Grant funds will pay for only administrative and fiscal intermediary services.

According to Indiana University, Center for Law and Health (Project the Need for Community-Based, Long-Term Care and Other Supportive Services in Indiana, July 1998), there are 978,099 person in Indiana over age 60. More than 240,000 of these persons experience some limitation in two or more "activities of daily living" (ADLs) such as bathing, dressing, or walking. In addition, there are 136,000 Hoosiers below age 60 who also experience limitations in these activities. More individuals wish assistance with community and in-home services programs that offer services to enable persons of all ages with disabilities to live independently in their homes and communities.

The elderly and persons with disabilities in Indiana who are able to remain in their own homes encounter problems related to personal services. Under the present system, case managers conduct needs assessments and design care plans, which may include personal assistance services. Although consumers may receive excellent personal care from providers, in the past they were not able to direct their own care, and hire, train or fire providers. Consumers and their families or caregivers have been offered a choice of providers. However, this typically was a choice of provider agencies, not of individuals specifically chosen by the consumer.

A. Analysis of Strengths and Challenges:

Indiana's support system for the aged and persons with disabilities in the community has important strengths which will be the foundation for this grant project. These include: 1) a well-designed community-based services program, the IN-Home Services Program; 2) Indiana's experience in using multiple funding streams; 3) Indiana's six Home and Community-Based Services (HCBS) waiver programs, and recent action by the Indiana General Assembly to increase state funds for matching Federal dollars to fund additional waiver slots; and 4) data management systems.

Indiana has received significant local and national recognition for its IN-Home Services Program. FSSA, through the Division of Disability, Aging and Rehabilitative Services (DDARS), administers the IN-Home Services Program. Implemented in July 1992, this program brings together funding from the Community and Home Options to Institutional Care for the Elderly and Disabled (CHOICE), Title III of the Older Americans Act, the Social Services Block Grant, the Older Hoosiers Account, six HCBS Waivers, the United States Department of Agriculture Meals program, and local and private funds.

During State Fiscal Year 2000, these funding streams provided services to 107,722 older Hoosiers and persons with disabilities. This includes 12,338 persons served through Indiana’s CHOICE program and 4,904 served through the five Medicaid Waivers in operation at this time. These persons were all at risk of losing their independence.

In 1997, the Hudson Institute reviewed the Indiana program in its publication, The Cost Effectiveness of Home Health Care: A Case Study of Indiana's In-Home/CHOICE Program. The authors positively reviewed the In-Home/CHOICE program as an example of a well managed, cost effective home care program. They also state that there is strong evidence that home care programs such as CHOICE can play a vital role in meeting consumer need and preventing institutionalization.

Another strength of Indiana's in-home services program is the six HCBS waiver programs administered by DDARS. These HCBS waivers target the aged and persons with disabilities, persons with developmental disabilities, persons with autism, persons requiring assisted living, children who are medically fragile, and individuals with a traumatic brain injury. The population that can currently be served by each of these waivers is: 2,500 (Aged and Disabled Waiver); 2,933 (ICR/MR Waiver); 200 (Autism Waiver); 350 (Assisted Living); 150 (Medically Fragile Children's Waiver), and 200 (Traumatic Brain Injury Waiver). The Indiana General Assembly funded additional slots for the Aged and Disabled Waiver (822 slots for Fiscal Year 2002, and 813 additional slots for Fiscal Year 2003). The Medicaid Waiver for Persons with Developmental Disabilities has been increased to serve up to 2,282 persons in the first year; an additional 722 persons the second year; and a further addition of 111 person the third year. This will bring the total availability of persons with developmental disabilities to be served through the Medicaid Waiver to 5,649.

Another strength of the Indiana IN-Home Services Program is its data management system. The INsite tracking system begins with data entry by case managers. Case managers enter information including demographics, functional assessments, level of care, family and community support systems, limitations in ADLs and instrumental activities of daily living, nutrition risk assessment, consumer goals, planned services, costs and frequency of services, funding sources, initiation and stop dates, quality assurance measures, and other data elements. This information is then electronically transmitted to the State office.

In 1998, the National Governor's Association highlighted Indiana for its use of interagency partnerships and innovations in preparing for the aging baby boomer generation. According to Transitions: States Prepare for the Aging of America, written by Jeannette M. Herick Ph.D., Indiana's approach to service delivery results in an individualized person centered planning approach, whereby the entire well being of the client and caretaker is considered in care planning. Older adults and individuals with disabilities can contact the AAA serving their area through a statewide all ages toll-free telephone number (1-800-986-3505) to access in-home and community-based services.

In an effort to promote quality assurance and improvement, DDARS recently established the Bureau of Quality Improvement Services, with Chris Newman as Director. This Bureau has developed provider standards for services to persons with developmental disabilities, quality improvement methodologies, monitoring techniques for 19 quality monitors (state staff) and data analysis to assure that consumers receive high quality services and that quality improvement is a continual process.

In a statewide demonstration project funded by the Robert Wood Johnson Foundation, the State of Indiana, AAAs, vendors, consumers, and Indiana University researchers worked together to use Total Quality Improvement techniques to improve the delivery of community-based long term care services. The resulting Quality Improvement Process (QIP) is now used by the 16 AAAs. It places an emphasis on measuring consumer choice, service outcomes, consumer satisfaction and numerous other domains. While providing consumer confidentiality, this system provides specific feedback to care providers to improve the services to consumers.

Indiana took important steps to be responsive to consumer’s wishes when it piloted a consumer directed attendant care program in 1999. Funded by the CHOICE program, it offers consumers the option of privately employing attendant care workers. Allowable activities include homemaker services, mobility assistance, meal planning and preparation, include homemaker services, mobility assistance, meal planning and preparation, dressing and grooming, and escort to medical appointments.

Problem Analysis:

The problems to be addressed in this grant application are: 1) creation of an enduring infrastructure to support consumer-directed personal assistance services; 2) education and information for older adults and persons with disabilities and their families or caregivers of these options; 3) assistance for consumers in recruiting and training providers; 4) expansion of the services available through consumer-direction; 5) ensure that consumers are not abandoned in their privacy and independence, but welcomed and integrated into their communities.

Recent reports for Indiana's Medicaid HCBS Waiver for the Aged and Disabled shows that Indiana currently has a total of 2,500 funded positions. Of the 2,338 receiving assistance under this waiver, 1,147 persons received attendant care services. Although these services will not be duplicated with grant funds, the numbers show that one-half of the persons receiving services through this Medicaid Waiver utilized attendant care services. However, these are not consumer-directed services. This grant will help move toward that goal.

The Medicaid Waiver for Persons with Developmental Disabilities has been re-written to implement numerous changes to make it more accessible and consumer focused. The previous version did not allow the provision of consumer-directed services. The new Waiver submission (under federal review at this time) has incorporated the principles of self-determination and self-direction.

Project Description and Methodology

Goals and Objectives:

The primary goal of this grant project is to create an enduring infrastructure to support consumer-directed personal assistance services. The first year of the grant will focus on designing this infrastructure for consumer-directed personal assistance services and gathering consumer input on the design. This process will also include amending the Aged and Disabled Medicaid Home and Community-Based Services Waiver to include consumer-directed care services.

Upon amendment, individuals will have the opportunity to use consumer-directed personal assistance services. By State Fiscal Year 2003 (July 1, 2002 - June 30, 2003), there will be 4,135 persons served through the Aged and Disabled Medicaid Waiver. It is anticipated that a range of 10 – 30 percent of Medicaid Waiver participants will choose to self-direct their own services. Based on a projection of 20%, approximately 827 persons would choose this option. All individuals who choose self-direction can access this option if they choose to, however.

Two additional Medicaid Waivers will be amended by the end of the second year of the grant period. These include the Medically Fragile Children’s (MFC) Medicaid Waiver (150 children) and the Traumatic Brain Injury (TBI) Medicaid Waiver (200 persons). Based on the assumption of 20% participation, this will equate to 30 children and families as well as 40 persons with traumatic brain injury choosing to self-direct attendant care services.

The Medicaid Waiver for Persons with Autism will be amended during the third year of the project. This Medicaid Waiver is approved to serve 400 persons in State Fiscal Year 2002. Indiana House Bill 1647 requires FSSA to apply for approval to increase the Autism Waiver by 200 slots before September 1, 2003. Additional funds will need to be appropriated to increase the number of slots by 100 between July 1, 2003 and June 30, 2004 and an additional 100 from July 1, 2004 to June 30, 2005. These additional funds will be included in FSSA’s biennial budget request for State Fiscal Years 2004 and 2005.

The Medicaid Waiver for Persons with Developmental Disabilities has been re-written and is undergoing review by CMS as of this time. The service components were written broadly enough to encompass a consumer-directed model. This is planned for implementation on October 1, 2001. Based on past estimates and experiences of other states, if 10% - 20% of the persons to be served through this Medicaid Waiver (5,649) choose consumer-directed attendant care, approximately 565 – 1,130 persons may participate in this new direction.

As the first objective, the State will establish a project advisory council through the Community Choice Commission. Membership of the Commission will include consumers of community-based and institutional services, advocacy groups, providers, state agencies such as FSSA, the State Department of Health, and the Department of Transportation. Collaborations and partnerships will also be established with the CHOICE Board, Governor's Council for Persons with Disabilities, Commission on Caregivers, Area Agencies on Aging, Independent Living Centers, Arc of Indiana, local advocates and organizations to achieve the grant objectives.

A well designed and community integrated program requires support and local collaboration with Indiana citizens. This must be based on shared experiences, data and information. Public input will be gathered through public hearings to be held around the state.

The second objective of the grant is to provide outreach and information. The Community Choice Commission will work with consultants, FSSA and local partners, e.g., AAAs and Independent Living Centers, to carry out this objective. Although some communities may be aware of consumer-directed personal attendant care services, a comprehensive education and outreach effort is needed. This will insure that older adults and persons with disabilities are informed and understand the options and responsibilities inherent in this program.

Other systems change grant initiatives submitted by Indiana include strong education and information components. Both the Nursing Facility Transition and the Real System Change grant proposals have education objectives that will be integrated with the objectives of this grant. In addition, participants in the direct services portion of the Nursing Facility Transition Grant will be given the opportunity to choose consumer-directed attendant care services.

The third objective of the grant will be the development of a consumer-directed personal assistance services model and the infrastructure needed to support it. This will involve collaboration with the Indiana State Department of Health, Independent Living Centers, AAAs, Arc of Indiana, the Governor’s Planning Council for People with Disabilities, and other partners. The infrastructure includes: training components for consumers and providers; establishment and utilization of fiscal intermediaries; claims payment systems through the Medicaid contractor (EDS); database infrastructure; provider qualifications (provider registry and certification); back-up support; risk management; and provider standards.

Success of the system change is the ability of the personal attendant to be fairly compensated within a reasonable timeframe. As the local administrative entity for the CHOICE program, the Area Agencies on Aging have established a history of paying claims within 30 days (and most often sooner). Because most attendant care workers may not be directly submitting claims electronically for EDS to process, a fourth grant objective will be to establish a fiscal agent process to insure accurate and timely claims payment and /or system changes to the Medicaid contractor system to insure timely payment.

The fifth objective of the grant will be to provide enhanced training for state staff and local providers. Case managers will receive additional training on the newly designed consumer directed attendant care model. This will further emphasize consumer choice, person-centered planning, quality assurance and fiscal agent coordination.

Grant funds will pay only for administrative and fiscal intermediary services. Indiana will continue to evaluate the service delivery mechanisms throughout the grant period. Lessons learned through these direct services will be used to enhance delivery systems, collect data on the cost and utilization of services, and to assess the adequacy and quality of services, and the impact on quality of life.

Sixth, system change initiatives will be comprehensive in scope and focus on enduring change. These changes are intended to: ensure that persons choosing self-directed care will not be abandoned or neglected by their caregivers or case managers; ensure that consumers have an adequate supply of capable personal attendants to choose from; provide methods to insure emergency back-up; provide quality assurance to guarantee an infrastructure that is responsive to consumer problems and effects timely problem resolution; ensure that consumers have maximized choice without facing undue risks; support or provide required personnel activities such as wage withholding; and provide the information and assistance to consumers necessary to carry out their tasks as new supervisors of attendant employees.

FSSA provides assurance that each of the Medicaid Waivers currently administered under its authority will include consumer-directed attendant care as a service option. These amendments will insure the long-term provision of consumer direction and personal choice.

Finally, lasting system changes can only be effective if they are based on data accumulated from the grant activities. The eighth, and final objective will result in outcome-based reporting. Evaluations will be conducted of the timeliness, adequacy and quality of the services provided. A key element to be examined is the quality of life of the project participants. That is, have the personal choices in attendant care improved their quality of life, resulted in increased involvement in the community, and added to their physical, emotional, and psychosocial well being? A principal evaluation component of this project will be to examine the outcome and impact of consumer-directed personal attendant care services on quality of life measures.

Methods of Effectively Addressing the Problem:

Description of Methods: The goals of this proposal are to design an effective and enduring infrastructure on which to build a successful consumer-directed personal assistance program. Indiana intends to use the majority of the grant funds for this purpose. The first year of the grant period will be used to garner input from consumers, develop policies, procedures and processes that will be used as a foundation for a lasting infrastructure. An objective of the grant is to develop partnerships to include the aging network in Indiana, Independent Living Centers, mental health networks, the developmentally disabled provider community, consumers, and advocacy groups.

Grant monies will be used to fund development and coordination of the infrastructure, and the design and implementation of the direct services project. Indiana will use the first year of the grant to secure two separate consultant services. The one function will be directed toward: insuring coordination and consistency of the approach of local partners; developing educational materials for providers and consumers; establishing specific outcome and impact measures; enable coordination of data analysis and data collection; facilitating reports and public presentations; and enhancing information and communication among all partners. A second function will be to work with the Community Choice Commission to design a model for consumer directed attendant care; focus on designing a fiscal intermediary program that can be used statewide for all Medicaid Waivers that have been amended to include personal directed care; and assist in preparing amendments for the Medicaid Waivers. Indiana will also use the first twelve months of the grant period to prepare and solicit local coalitions to participate in the grant projects of years two and three.

To ensure the interests and rights of individuals participating in the grant projects, the grant proposes to utilize State Long-Term Care Ombudsman, local ombudsmen, consumers, advocacy groups representing persons with developmental disabilities, and the Independent Living Centers in Indiana. Ombudsmen assisting in the transition/diversion project of Indiana's Nursing Facility Transition grant will also be educating nursing facility residents, their families and the general public about the consumer directed attendant care option, the rights of nursing facility residents to make choices and determine their living situations.

The Independent Living Centers will be solicited to provide self-advocacy, training and material development. The Indiana Council on Independent Living and the Independent Living Centers in Indiana will have roles in advocacy education. These services stress the theme of consumer control and direction.

The Adult Protective Services, Adult Guardianship Services, and the Money Management programs of FSSA may also be available to assist persons participating in the grant projects. Adult Protective Services will be a partner and advisor in assuring the safety and protection of consumers by investigating reports of abuse, neglect or exploitation of endangered adults. Adult Guardianship providers will be invited to participate in education and training sessions to enhance the ability of the consumers that they serve to be knowledgeable about these options. The Money Management program may be a resource to some consumers in managing finances and paying their bills.

Although the long-term goal of this project is to effect statewide system changes, specific areas of the state will be targeted for the grant projects. At least three areas will be chosen to participate in the grant projects for years two and three. Participants in the project will be receiving services through the Medicaid Waivers that will have been amended as grant objectives.

Another targeted area for the Community PASS grant will be an area in Indiana that is also participating in the Nursing Facility Transition Grant projects. Individuals in these areas who are either being transitioned or diverted back to their communities will also be offered consumer-directed attendant care services. Waiver funds will be the first payer for waiver-eligible individuals opting for consumer-directed attendant care services, while the Nursing Facility Transition grant funds will pay for services to support services specific to transition or diversion. Community PASS funds will be the payer for any additional services that are unique to the PASS grant, such as fiscal intermediary services.

If both projects are funded through these proposals the project would include four areas of Indiana that would constitute the following:

Nursing Home Transition - 20 consumers	Nursing Home Transition and Community PASS – 20 consumers
Nursing Home Diversion - 20 consumers	Community PASS

As in Indiana's Nursing Facility Transition grant proposal, a request for proposal (RFP) will be used to solicit consultants and other participants in the grant. A condition of participation will be the applicant's ability to collaborate with local partners including Independent Living Centers, Community Mental Health Centers, Area Agencies on Aging, home health agencies, local offices of the Bureau of Developmental Disabilities Services (BDDS) and other organizations. Other conditions of participation will be: outreach efforts to assure sufficient provider capacity, consumer involvement in recruiting attendant care providers, emergency back-up procedures, quality assurance, fiscal agent assistance, training and support.

No predetermined age or disability restriction will apply to participants in the grant project. Indiana will address the question of how individuals with the most severe disabilities may benefit from systems improvements through project monitoring and evaluation. Persons participating in this service will be monitored for costs, quality of life issues, consumer satisfaction, hours of service, and other factors to be designed. Persons participating in the direct service project of the grant will receive personal attendant services, will have training available to assist in directing their efforts, and will have available the assistance of a fiscal intermediary.

Allowable activities for these personal attendants will be: homemaker activities; mobility assistance; transfers; nutrition (meal planning and preparation); elimination assistance; safety issues and procedures; assistance with bathing, medication management; assistance with ADLs; escorting consumers to medical appointments; and correspondence and payment of bills. In general, the consumer can direct the attendant worker to perform activities that the consumer could perform if a disability did not exist. Under Indiana law (SEA 215), the attending physician must state that the consumer can self-direct their own care, the attendant worker must be trained by a licensed health care professional and a contract must be signed between the parties.

Reasonableness of Methods and Expression of Confidence: Indiana's experiences with the CHOICE pilot program for Consumer Directed Attendant Care demonstrates that an expanded and improved program will be highly beneficial to an expanded population. The participating AAAs, consumers, their families and caregivers, and providers reported positive results from this pilot program. All parties wish the program to be refined and expanded.

Coordination and Linkages:

Complementary Initiatives: Realizing that a successful systems change for a consumer-directed program involves the promotion of self-advocacy, the protection of consumers rights and well-being, and a network of community providers, the Community Choice Commission will oversee these projects. To maximize the impact and lasting system change, the State is submitting three grant proposals. These include the Community PASS proposal, Nursing Facility Transition proposal and Real Systems Change proposal. Linkages will be established with the AAAs, the State Long-Term Care Ombudsman, Independent Living Centers, Adult Protective Services, nursing facility associations, the Indiana Association for Home and Hospice Care, and the Indiana Assisted Living Association. As the largest agency of Indiana State government, FSSA includes approximately 11,000 employees. As one Division within FSSA, DDARS brings expertise in its Bureaus of Developmental Disabilities Services (BDDS), Fiscal Services, Aging and In-Home Services, Strategic Support Services, Rehabilitative Services, and Quality Improvement Services. FSSA will coordinate these activities with other state agencies and Indiana's other systems change initiatives described above.

The Office of Medicaid Policy and Planning (OMPP), a part of FSSA, will play a central role in working with the local partners and providing direction for the consumer-directed attendant care initiative. Upon notification of the grant award, OMPP and other collaborators will initiate plans to implement the goals and objectives of the consumer-directed attendant care project. These collaborators have supported, in principle, transition efforts and the resulting options available to consumers, and can assist in disseminating information to consumers among other activities. (see Appendix B for Letters of Support).

Finally, the RFP process listed in the work plan will specify local coordination and cooperation as the condition of participation in this grant project. For this grant, the RFP will also state that on-going support for the direct service project will be required of participants. For direct service projects overlapping with the nursing facility transition and diversion projects, only coalitions of local AAAs, nursing facilities, local BDDS offices, Community Mental Health Centers, Independent Living Centers, ombudsmen, home care providers and assisted living facilities who agree to implement the consumer-directed attendant care program and provide on-going support of the project will be selected to participate in this effort.

Coordination with Other Funding Sources: Indiana's Statewide IN-Home Services Program brings together funding from the CHOICE program, Title III of the Older Americans Act, the Social Services Block Grant, the Older Hoosiers Account, six Home and Community-Based Medicaid waivers, the U.S. Department of Agriculture Meals program, and local and private funds. Each participant will be assessed for continuing supports from all available sources. As Medicaid Waiver amendments are approved, they will be the payer for consumer-directed attendant care services. Indiana's other funding sources will also be adapted to pay for consumer-directed support services before grant funds expire.

3. Commitment from Partners: The Commission will also partner with the CHOICE Board, the Governor's Planning Council for People with Disabilities, Arc of Indiana, Indiana Association of Rehabilitation Facilities, Indiana Assisted Living Federation of America, Indiana Association for Home and Hospice Care, Commission on Aging, Indiana Association of Homes and Services for the Aging, Indiana Council on Independent Living, and Indiana Health Care Association. The roles of these organizations are described further in the Partnerships section of this proposal.

Work Plan:

The Commission, through FSSA, will address infrastructure development and system issues through the following grant activities: 1) planning and grant administration; 2) development/enhancement of the models to be tested; 3) development of tools needed, such as assessment tools, budget development process, fiscal intermediary and other service assistance programs; 4) education and outreach; 5) enhanced case management training; 6) implementation of the direct services projects, and 6) outcome evaluation and reporting.

Objective 1. To develop a system design for a successful consumer directed attendant care program.

Action Step 1.1 Formation of the Community Choice Commission. This board will consist of individuals representing consumers, providers and state agencies. This Commission will monitor the planning, implementation, and evaluation of the overall grant project as well as the other two grant initiatives and implementation of Indiana’s Comprehensive Plan for Community Integration and Support of Persons with Disabilities (Community Integration Plan). The initial meeting will occur by October 1, 2001.

Action Step 1.2 Development of a Request for Proposal (RFP) for project management consulting services. The RFP will be used for the consultant services to coordinate and manage the grant implementation. Indiana plans to devote the first year of the grant period to gaining consumer input, developing the policies, procedures and processes which will build the infrastructure for a lasting consumer-directed attendant care program. The consultant will work with the Commission to achieve this goal. The RFP will be finalized by December 1, 2001 with selection of a consulting form to be made as soon as possible.

Action Step 1.3 Development of an RFP for consumer-directed care specialized consulting services. The RFP will be used for consultant services to develop a consumer-directed attendant care model that includes a fiscal intermediary program. The consultant will work with the Commission to achieve this goal. The RFP will be finalized by December 1, 2002 with selection of a consulting firm to be made within 60 days.

Action Step 1.4 Development of an RFP for local coalitions. This process will be used to obtain coalitions of participants in the direct service project including consumers, AAAs, assisted living facilities, Independent Living Centers, and vendors. A minimum of three local coalitions will be funded and all coalitions must agree to participate in achieving the goals of the grant project. The RFP will be finalized by March 1, 2002 and participants selected within 60 days.

Action Step 1.5 Development of an RFP for participants in the education and outreach project. This RFP will solicit participants such as the Indiana Council on Independent Living, the Independent Living Centers in Indiana, AAAs, Arc of Indiana, Indiana Parent Information Network, local colleges and universities, and other entities to conduct education and outreach programs. These programs will be directed to consumers, families, caregivers, local communities, and potential providers. The RFP will be finalized by March 1, 2002 and participants selected within 60 days.

Action Step 1.6 Execution of contracts. The execution or amendment of contracts will occur within 60 days of the selection of vendors through the BAA process in #1 above.

Objective 2. To plan a consumer-directed attendant care model; to plan education and outreach programs; to develop informational materials.

Action Step 2.1 To develop a model for consumer-directed attendant care using the services of the specialized consultant who has experience in designing programs, especially in fiscal services. The consumer-directed attendant care model will be completed by September 1, 2002.

Action Step 2.2 To plan and design education and outreach programs using the services of the project management consultant, with approval of the Commission. Education and outreach programs to be designed by September1, 2002.

Action Step 2.3 To develop educational materials about the model consumer-directed attendant care program, using the efforts of the specialized consultant, the Commission, and local coalitions. Educational materials to be developed by September 1, 2002.

Objective 3. To provide information to individuals eligible for personal directed attendant care funds; to provide statewide outreach services focused on educating consumers, families, caregivers, providers, local organizations, and other advocacy organizations about consumer directed attendant care options; to train case managers and hospital discharge planners.

Action Step 3.1 To disseminate information to residents in nursing facilities, group homes, and large private ICF/MR facilities about consumer-directed attendant care opportunities, with the goal of enrolling several persons who are also participants in the Nursing Facility Transition grant projects. Information will be provided by October 1, 2002 and on-going.

Action Step 3.2 To provide nursing home facilities and hospital discharge planners with information and training on Indiana's consumer directed attendant care program. Information will be provided by October 1, 2002 and on-going.

Action Step 3.3 To contact all potential local providers with information about the consumer directed attendant care program. This will include training opportunities for direct care workers to "accept" consumer-directed care. Contact to be made by October 1, 2002 and on-going.

Action Step 3.4 Specialized training. Case managers will be identified to work on the consumer directed attendant care project. These case managers will be identified within 30 days of the contract with participating local coalitions. Curriculum development will begin within 30 days of the grant award. Training will be conducted by September 30, 2002.

Objective 4. To collaborate with community entities to provide statewide outreach services focused on the consumer-directed personal attendant option.

Action Step 4.1 Coordination with Area Agencies on Aging, Independent Living Centers, Arc of Indiana, Indiana Association of Rehabilitation Facilities, and other local organizations. Representatives from these groups will plan and implement outreach events and dissemination activities; and will develop further networks and coalitions of participants in the education/outreach effort. Plans with these associations will be implemented by November 1, 2002.

Action Step 4.2 Collaborators in the statewide education and outreach program will disseminate materials at the FSSA outreach events: Celebration for Older American's Month in May, senior citizen programming at the Indiana State Fair; the Indiana Governor's Conference on Aging and In-Home Services and other events. Planning for participation in these events will begin by March 2002.

Objective 5. Amend the HCBS Waivers to include consumer-directed attendant care.

Action Step 5.1 Development of a process to amend the Medicaid Waivers. The specialized consumer-directed care consultant will work with the Commission and DDARS to develop a service model for consumer- directed attendant care. The model will be designed by March 1, 2002.

Action Step 5.2 The Bureau of Fiscal Services will write amendments to the Aged and Disabled (A&D) Waiver and submit it to CMS by June 1, 2002 to allow for a 90 day review. The target date for implementation of the amended A & D Waiver is October 1, 2002.

Action Step 5.3 The Bureau of Fiscal Services will submit amendments to the Traumatic Brain Injury Waiver to include consumer directed attendant care to CMS by June 1, 2003 to allow for a 90 day review. The target date for implementation of the amended TBI Waiver is October 1, 2003.

Action Step 5.4 The Bureau of Fiscal Services will write amendments to the Medically Fragile Children's Waiver and submit it to CMS by June 1, 2003 to allow for a 90 day review. The target date for receipt of the amended MFC Waiver is October 1, 2003.

Action Step 5.5 The Bureau of Fiscal Services will write amendments to the Autism Waiver and submit it to CMS by June 1, 2004 to allow for a 90 day review. The target date for the review of the amended Autism Waiver is October 1, 2004.

Objective 6. Selection of eligible candidates to receive personal attendant care services.

Action Step 6.1 Identification of Medicaid Waiver eligible participants in this project will be based on the analysis of residents conducted for the Nursing Facility Transition Grant, and outreach activities to consumers currently living in the community. A refined, updated analysis including individual resident identification will be completed by September 30, 2002.

Action Step 6.2 Selection of participants. After nursing facility residents are identified by functional data (see 6.1 above), they will be notified in person and in writing. The remainder of the participants will be self-selected as on-going reviews are conducted and consumers are offered choices for services. The initial contacts will be made by October 2002 and participants will be notified within 60 days of identification.

Action Step 6.3 Development of individualized care plans. The development of a person-centered plan and an individualized plan of care will begin with the initial contact between the case manager and the grant participant. At least 50% of all plans will be completed within 30 days of this contact. The remaining plans will be completed within 60 days of this contact with any modifications made as necessary.

Action Step 6.4 Coordination of consumer directed attendant care services. Case managers, Independent Living Centers, Ombudsman and other local collaborators will provide participants with information or contacts on how to hire, train or dismiss personal attendants and how to use emergency back-up systems and other necessary information. Collaboration to begin within 30 days of selection of participants.

Action Step 6.5 Selection of direct services participants for the third year of the grant. Persons who are eligible for the Medically Fragile Children’s Waiver or the Traumatic Brain Injury Waivers will be candidates to receive consumer-directed personal assistance services beginning on October 4, 2003. The same processes outlined in #6.2 to #6.4 will be followed for these persons.

Objective 7. Systems Change

Action Step 7.1 As a result of training, outreach and information initiatives, increase consumer choice and enable individuals to receive the types of services they desire in the location they prefer. All local partners will facilitate person-centered planning initiatives. Enhanced choices to begin with the development of individualized care plans for grant participants, beginning October 1, 2002.

Action Step 7.2 Support the informal network of families, friends, neighbors and communities. This will be accomplished by encouraging families and advocates to actively participate in systems development, person-centered planning, education, and caregiver support initiatives, beginning October 1, 2001.

Action Step 7.3 Strengthen quality assurance, monitoring systems, complaint systems and advocacy efforts. DDARS, through the Bureau of Quality Improvement Services, will work with the Commission to enhance consumer advocacy programs, assure oversight and accountability for quality assurance activities, and insure that conflicts of interest do not exist.

Action Step 7.4 Increase the system capacity for the provision of high quality care. The Commission and its member agencies will work with DDARS and OMPP to address transportation, employment and housing needs. The focus on this examination is to determine if there is a way to provide more consumer direction and choice for these support needs.

Action Step 7.5 Create a coordinated workforce development system that recruits and supports a stable resource of providers, or direct support staff. The Commission will work with FSSA and the Indiana Department of Workforce Development (DWD) in enhancing the training and recruitment of attendant care workers. Provider standards will be determined, especially for persons with developmental disabilities where a family member or legal representative makes the decisions, and the Bureau of Quality Improvement Services will promulgate these by March 1, 2002.

Action Step 7.6 Examine barriers to recruiting and maintaining quality workers. The Commission will work with FSSA, DWD, the Indiana Department of Commerce and others in this effort. This will be part of the Commission's work, beginning on October 1, 2001. Under consideration in the development process for the consumer directed attendant care model is the option of providers to negotiate their rates with their consumer employers.

Action Step 7.7 System change beyond Medicaid Waivers. Currently the Medicaid Waivers do not service persons with a sole diagnosis of mental illness. System change activities will address methods for these individuals to access consumer-directed care and work with the Division of Mental Health and the Hoosier Assurance Program.

Objective 8. Evaluation and Report Preparation

Action Step 8.1 Data collection tool. The grant proposes to build on the INsite database to record: the cost and units of personal attendant services, number of providers, costs and time to manage the fiscal activities for consumers, demographics of participants, ICD-9 codes of participants, and total costs of services. Modifications to INsite may be necessary to identify these consumers and include additional elements that are deemed necessary. All modifications will be finalized by September 30, 2002.

Action Step 8.2 Development of outcome-based reports. Indiana will comply and meet all reporting timeframes specified for the grant process. Working with the Commission and project consultants, outcome-based reports will be developed that identify the impact of the grant. Measures to be studied include: quality of care, quality of life, costs, numbers of providers utilized, consumers need for additional assistance from AAAs to manage their personal attendants, identification of any safety valve or care issues that arose during the grant project; an description of the positive and negative effects of the program. Reports shall be submitted at quarterly, annual, and project end intervals.

Organization, Management and Qualifications

Circumstances Effecting the Ability to Recruit and Hire Staff: FSSA will use an RFP to solicit applicants for contract employment. Contracts are then prepared for selected candidates and forwarded to through the state approved process.
Qualifications of Key Project Staff, Stakeholders and Partners: This project will be overseen by the office of Governor Frank O’Bannon, with FSSA serving as the lead agency. This will involve coordination of the local coalitions, solicitation and review of RFPs, coordination of the Ombudsman program, activities related to INsite software and reporting, and coordination of case manager training. FSSA, through DDARS, will have contractual relationships with: consultant(s) to oversee and coordinate the project; local entities selected to participate in the grant projects; and with the Independent Living Centers contracted to implement the education and outreach objectives.

The Office of Medicaid Policy and Planning (OMPP), as part of FSSA, is the Medicaid Single State Agency and will be a major partner in this grant effort. In addition to oversight and administrative duties, OMPP will help develop and authorize the amendments to the Medicaid Waivers.

Ms. Alison Becker, Director of DDARS’s Bureau of Fiscal Services, is coordinating Indiana's application for the system change grants as well as implementation of the Community Integration Plan. Ms. Becker, along with Ms. Jackie Pitman and Ms. Chris Newman, will be the liaisons with the Community Choice Commission. Ms. Angela Spittal, Deputy Secretary of FSSA, will coordinate efforts between FSSA and the Governor’s Office.

Mr. Robert Hornyak, Assistant Director of the Bureau of Aging and In-Home Services (BAIHS), will allocate 5 % of his time to the performance of his project duties. Ms. Dortha Joyce, Assistant Director of Field Services for DDARS's Bureau of Developmental Disability Services (BDDS), will allocate 5% of her time providing coordination with this grant and the local BDDS offices and the state office. Ms. Carol Warner, Unit Manager for Program Planning and Program Assistance Functions, has 10% of her time allocated as Project Manager for this grant. She will supervise, direct, and support the activities of the Grant Coordinator, consult with the persons or agencies contracted to consult for the grant, and provide technical advice in the development of materials and reports. Ms. Patty Matkovic is the Grant Coordinator with 25% of her time allocated to the following grant projects: work with Commission and the project consultant in the administration of this grant, reviews of the participating facilities, technical expertise, educational efforts, research for materials development and report compilation.

A copy of the resumes for Ms. Becker, Ms. Pitman, Ms. Newman, Ms. Spittal, Mr. Hornyak, Ms. Joyce, Ms. Warner and Ms. Matkovic are located in Appendix C of this application.

Direct Professional Experience with Disabilities or Long Term Illnesses: Prior to his current position as Assistant Director of BAIHS, Robert Hornyak was employed as a vocational rehabilitation counselor, counselor supervisor and program director. He has also worked with youthful offenders, individuals with developmental disabilities and individuals with mental illness, utilizing his Masters degree in Clinical Psychology. He is a Licensed Clinical Social Worker.

Carol Warner serves in the development and implementation of program policies and procedures and has experience working with nursing facilities and community groups. She has in-depth knowledge about Medicaid policies and procedures having assisted in the development of Indiana's PASRR program. Prior to her present employment, Carol worked as a case manager for the Indiana Department of Mental Health; as a program director and instructor for Woodlawn Center, a rehabilitation center for persons with developmental disabilities; and as a special needs teacher in the public schools.

Patty Matkovic brings to her position of grant writer a strong background in research and reference as a former librarian. She was employed at the Indiana State Library. Prior to her current employment, Patty managed a medical library.

Significant Roles of Persons with Disabilities or Long Term Illness: Persons with disabilities will be integral members of the Community Choice Commission. The Independent Living Centers in Indiana will have a significant role in advocacy, training, outreach, and information and assistance activities. This proposal has been taken to meetings attended by advocacy organizations, consumers, and providers. Direction and comments received as a result of those meetings have been incorporated into the grant. In addition, continued and regular dialogue will be established with Independent Living Centers and other consumer directed organizations. The Independent Living Centers especially will have major roles in the development of educational materials, training of consumers, and identification of persons appropriate for consumer directed attendant care services. The Commission will have a Consumer Taskforce as well as on-gong public dialogue and feedback.

Significance

Enduring Change:

The state has clearly expressed its commitment to creating enduring system changes in integrating persons with disabilities into community-based living. The June 1, 2001 publication of the FSSA entitled Indiana's Comprehensive Plan for Community Integration and Support of Persons with Disabilities (Community Integration Plan) outlined the following six major policy directions that will advance the development of community-based services: 1) emphasize consumer choice: enable individuals to receive the types of services they desire in the location they prefer; 2) provide information, assistance and access to consumers to increase their opportunity for informed choice; 3) support the informal network of families, friends, neighbors and communities; 4) strengthen quality assurance, monitoring systems, complaint systems and advocacy efforts; 5) increase the system capacity for provision of high quality care; and 6) create a coordinated workforce development system that recruits and supports a stable resource of direct support staff.

The Commission, in implementing the Community Integration Plan and the grant proposals, will also use these policy directives as their system change goals. The Commission will be charged with recommending and monitoring changes to the system; providing on-going dialog regarding the success and challenge of the grant projects; and continuing to have regular meetings to report on the progress the state has made, and to be a forum for concerns of Indiana's citizens.

The Indiana General Assembly recently passed legislation that expands the options of care available to individuals through a continuum of care. FSSA must submit a preliminary plan to assure that services provided to the elderly or persons with disabilities match the needs of these persons as closely as possible. It must include specific options available to these persons, the costs of such care, the availability of waivers through the Medicaid program, and the effects on the quality of life for the consumers and their families. Activities and outcomes from this grant will further enable FSSA to provide a responsive, consumer-oriented plan. This plan will include items addressed in the grant proposals and Community Integration Plan.

Assistance with Key Goals and Objectives:

This grant will provide Indiana with important data, case management experience, local collaborations, consumer information, and administrative experience to assist the state in creating enduring systems of change. The grant projects concentrate on providing individuals with maximum personal choice in hiring their personal attendants, thereby increasing their quality of life and independence. The grant also focuses on developing enduring systems change, and utilizes unique partnerships of public and private organizations to achieve these objectives. Finally, the grant intends to promote local, community involvement through using local coalitions to solicit participants in the grant projects and through enlisting the support of local providers, many of whom may not be familiar with consumer directed personal assistance services.

Sustainability:

The State has taken steps to ensure that changes in the system endure after the grant period. One of the most critical factors in selecting the participating local coalitions for the direct services project is that funding for personal attendant care services will continue to individuals after grant funds have been exhausted. Local entities such as the AAAs, Independent Living Centers, and the Bureau of Developmental Disabilities Services (BDDS) offices can access many contracted public funding sources beyond the Medicaid HCBS Waivers, and the use of some of these funds could be appropriate for services for the targeted population. During State Fiscal Year 1998, $4 million of the total IN-Home Services Budget consisted of local funds at the Area Agency on Aging level. Several Area Agencies on Aging have inquired into the use of these funds as match for Medicaid HCBS Waivers. If successful in this grant solicitation, Indiana will pursue the mechanism to obtain Federal Financial Participation (FFP) for these local dollars. This will be a creative mechanism to increase local commitment to statewide initiatives and expand the impact of these local funds.

Indiana's IN-Home Services Program has another significant strength that will be called upon to sustain these grant projects -- blended funding. Each AAA can draw upon the resources available through the funds described under the IN-Home Services Program. Using these blended funds means that, at the end of the grant period, the individual may have access to funds from the Aged and Disabled Waiver, the CHOICE program, or other funds which may be available from local sources.

A selection criterion for participants in the grant projects is that they must be eligible for either the CHOICE program (state funded) or a Medicaid Waiver. Participants in the grant projects will have access to Medicaid prior authorizations to access home health funds. FSSA provides assurance that amendments to the Medicaid Waivers will be submitted to incorporate consumer directed care.

Partnerships

Consumer Partners

In addition to the Community Choice Commission, the Indiana CHOICE Board, ARC of Indiana, Indiana Association of Rehabilitation Facilities, the Indiana Governor's Planning Council for People with Disabilities, and others will be involved in the grant process by providing representation for the grant. The CHOICE Board consists of people who represent senior citizens, individuals with disabilities, persons with mental illnesses, providers, home care services advocates, and a gerontology specialist.

The Indiana Governor's Planning Council for People with Disabilities is composed of persons with disabilities or family members of disabled people who are active in advocacy work. The Council is a strong advocate for the issues and rights of persons with disabilities and will be vocal in its support of in-home services programs that affect quality of life issues.

The Commission will represent a variety of experiences and knowledge. Foremost will be the voice of consumers who will be represented by individuals and organizations. The Commission will bring together the PASS grant with the other system change grants Indiana is applying for: Nursing Facility Transition, and Real Choice System Change Grants.

Finally, local partnerships are the key mechanism to assure the success of this endeavor and future efforts. The solicitation of local projects will help assure the commitment of these partners. Only the local coalition proposals that clearly describe a significant level of partnership and commitment on the behalf of local partnerships will be awarded funds through this grant.

Public/Private Partnerships

This project will require the establishment of a number of partnerships necessary to provide consumer-directed attendant care services, and establish systems changes. The Commission, through FSSA, will establish partnerships with: the Indiana Assisted Living Federation of America, the Indiana Association of Area Agencies on Aging, the Indiana Association for Home and Hospice Care, the Indiana Association of Homes and Services for the Aging, the Indiana Council on Independent Living, AARP, Arc of Indiana, Indiana Association of Rehabilitation Facilities, the Indiana Health Care Association, the Indiana Home Care Task Force (a coalition of over 30 advocacy groups), United Senior Action, and primary consumers and their families.

Initial discussions with many of these groups have revealed enthusiastic support for this grant submission. The enclosed letters of support describe how they will help in implementing the grant objectives, and assist in making system changes.

Formative Learning

Mechanism for Tracking Program Goals, Objectives and Outcomes:

The monitoring plan will be one of the critical elements of the consumer-directed attendant care project of the grant, especially for the participants who are returning to their communities from nursing home placement. Case managers will be in frequent contact with individuals to monitor if they are receiving all of the necessary services and have the necessary information to access the service array available and report any unresolved issues. Current practice requires case managers to have face-to-face contact with each consumer at least every 90 days.

Systems-level monitoring will also take place for the entire project. The grant managers and project consultant will visit project sites on a regular basis throughout the grant period. The project consultant will also frequently visit sites with the local case managers to assure that the project is proceeding according to the stated expectations and time-lines. The Commission will track grant objectives to facilitate change and public discussion.

Means of Incorporating Feedback into the Project's Ongoing Operations:

The FSSA and the Indiana University Center for Law and Health were partners in a demonstration quality assurance grant from the Robert Wood Johnson Foundation. The grant resulted in an intervention strategy, the Quality Improvement Process (QIP), which has been expanded for statewide use through all 16 AAAs. Consumers are questioned on a number of areas. Consumer confidentiality is first protected, then scores are aggregated and provided to vendors to improve the quality of services. QIP will be amended to include the individuals involved in the direct services project of this grant.

Information will also gathered from case managers, facilities and other individuals. FSSA and the Commission will analyze this information. Interim results will be shared, and mechanisms created for the participating local coalitions to share what they have learned and build upon each other's experiences.

The Bureau of Quality Improvement Services (BQIS) has developed provider standards, monitoring mechanisms and staff, and processes of inclusion for persons with developmental disabilities. Transition, diversion, and community inclusion are focal points for BQIS. Persons involved in this grant who have a developmental disability will be monitored by the 19 field monitors under BQIS. This in-depth monitoring and tracking will also be used in best practice studies for the entire population receiving services and for system change activities.

Budget and Resources

Please see budget submission for all details on this proposal.

For this project, FSSA is submitting a total budget of $1,463,469 ($1,147,500 federal and $315,969 state). State funds will be from Indiana’s CHOICE program. This is a 100% state funded account. This amount exceeds the required 5 percent in-kind or third-part contribution.

The program narrative details the activities to be carried out through this proposal. Grant funds will not be used to supplant or replace existing state or federal funds.

Budget Justification (Federal)

TRAVEL                                                  $8,700

Out-of-state conference attendance and in-state monitoring.

SOFTWARE                                               $25,000

Modifications to current database(s) to track project demographics, costs, time, and outcomes.

TRAINING                                               $21,889

Training will be conducted for consumers, case managers, Independent Living Centers, and others involved in this process. This will focus on person-centered planning, consumer direction, fiscal intermediaries and other relevant issues.

CONSULTANTS                                           $375,000

Consultants will be solicited to provide expertise in project design, material development, monitoring, training, evaluation design and reporting. Staff from states that are operating successful consumer-directed projects (maximum of two) will be invited to Indiana to learn from their experience. Based on a cost of $150/hour, this includes: 25 hours per week in year one; 15 hours per week in year two; and 10 hours per week in year three.

LOCAL ADMINISTRATION                                  $468,000

Local coalitions will be developed to implement this project. These projects will be led by Area Agencies on Aging (minimum of 3 – total funds $234,000) and Independent Living Centers (minimum of 3 – total funds $234,000).

CASE MANAGEMENT                                        $73,711

Cost of case management services ($38.39) not billable under current processes. This includes planning and coordinating activities while residents are in nursing facilities, services to persons not yet Medicaid eligible and services to persons on waiting lists.

HOME-BASED SERVICES                                   $175,200

Attendant care services are planned to be paid through the Medicaid Waiver programs. These funds are budgeted for exceptional instances, e.g., recipient loses Medicaid eligibility, provision of emergency service while waiting for final eligibility determination.

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