PAS Session 042308 Presentations by 2ix90rw8

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									Making Personal
Assistance Services
Work for People
with Disabilities
MIG/DMIE Employment Summit
April 23, 2008
New Orleans, Louisiana
2
Work Opportunities Reward Kansans
            (WORK)
 Supports that Improve Independence and
               Employment
        3
What is WORK

 Package of services to support
  employed people with disabilities who
  need Personal Assistance Services to
  go to work or increase current hours.
 Cash and Counseling Model –goes
  one step beyond self-direction.
 Must be eligible for the Medicaid Buy-
  in (Working Healthy)
4
Unique Features

 More choice and options than
  traditional HCBS services in Kansas
 Provides ability to work more and
  save more $
 More freedom to control who provides
  services, and how funds are spent
  (e.g. wages for PAS).


5
WORK Eligibility

   Employed FICA/SECA payments
   Kansas resident
   16-64 years of age
   SSA Disability determination
   Earnings over $65/month and Federal
    Minimum Wage
   Eligibility for the Physical Disability,
    Developmental Disability, or Traumatic
    Brain Injury Waiver or waiting list or
    demonstrate the same need for supports.
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WORK Services


 Personal Attendant Services
 Assistive Services

 Independent Living Counseling




7
Personal Assistance
Services
   Funded via monthly allocation
   Based on hours of care determined during
    the assessment
   Can choose to use PAS or alternative to
    PAS and are provided at home and worksite
   Can choose to use fiscal manager or be
    their own (with training)
   Can choose to self-direct or agency-direct
    services

8
Examples of Alternatives to
PAS

 Lawn service
 Meals on Wheels

 Public transportation cost

 Microwave oven

 Top loading dryer




9
Assistive Services

    Defined as any item , piece of
     equipment, or environmental
     modification, which is used to
     increase, maintain, or improve
     independence, employment, and/or
     health and safety.



10
 Some approved uses for
 Assistive Services

 Unique modifications to a van
 Electric power lift

 Electric generator

 Lift chair

 New remote control for van lift




 11
Independent Living
Counseling
 Consumers who feel they can
  coordinate their services without the
  assistance of an ILC have the option
  to do so
 KHPA reserves the right to require
  that consumers use an ILC if they
  have concerns about a consumers
  safety or health.

12
     WORK Enrollment
   Program began July 1, 2007
   Anticipated 50-100 enrolled during first year
   Slow process to set up WORK
   Enrollment December, 2008
       Working Healthy   1,019
       WORK                 18
   Enrollment April, 2008
       Working Healthy   1,025
       WORK                 50
     13
         WORK Enrollment
         (Allocations sent at the beginning of each
         month)

50
45
40
35
30
25
20
15
10
5
0
     Sept. 07   Oct. 07   Nov. 07   Dec. 07   Jan. 08   Feb. 08   Mar. 08   Apr. 08
          14
WORK Allocations

 WORK consumers have varying
  levels of need.
 Lowest cost - 24 hours per month,
  $344.00 allocation per month
 Highest cost – 476 hours per month,
  $6,311.00 allocation per month
 Average cost plan - $1,880.00 per
  month
15
Barriers Encountered
    Slow enrollment of providers
        Not business as usual
    Slow enrollment of beneficiaries
        Wanted to see how this would work for
         others before enrolling
    Unique features of the program seemed
     difficult to understand
    More training
        Eligibility workers
        IL Counselors
        Consumers

16
Positive Outcomes Reported

 More independence and choice
  regarding self vs agency direction
 Ability to purchase things with their
  wages that are needed and wanted
 Employer reports receiving the best
  from their worker



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Serving People with Mental
   Health Disabilities in
  Utah’s EPAS Program
 Cognitive and Behavioral Cuing

            Carol Ruddell
   Project Director, Work Ability Utah



                              Work Ability Utah
                              Utah’s Medicaid Infrastructure Grant
                              CMS #11-P-92406-8/04            19
       EPAS Participants
Numbers of Participants
• Currently 89 active participants
• 239 applicants since 7/01/03

Disabilities
• Self report by applicant
  and / or
• As noted by clinician completing MDS-HC
  and/or BSI

                                            20
   Participant Demographics
• Developmental Disabilities
    current 44, cumulative 116
• 4 Traumatic or Acquired Brain Injury
   current 4, cumulative 27
• 24 Mental Illness or Psychiatric Disability
   current 24, cumulative 59
• 13 with Physical Disability
   current 13, cumulative 37
                                                21
      State Plan Amendment

• Have a disability
• Be eligible for Medicaid (including buy-in)
• Gainfully employed or promise of a job, in
  an integrated setting
• Work at least 40 hours per month
• Need personal assistance to work


                                                22
           EPAS Services
“Services include physical assistance
and cognitive cuing to direct self-
performance of necessary activities.”

 Activities of daily living
 Instrumental activities of daily living


                                            23
    Eligibility & Services Process
• Assessment:
    – MDS-HC (Minimum Data Set – Home Care)
    – BSI (Brief Symptom Inventory), a supplemental
      tool
•   Interview with Specialist
•   Determination made
•   Plan Developed
•   Personal Assistants hired
•   Services begin
                                                      24
 Cognitive and Behavior Indicators
• Assessment:
  – MDS-HC (Minimum Data Set - Home Care)
     • Section B Cognitive Patterns
     • Section E Mood and Behavior Patterns
  – BSI (Brief Symptom Inventory)
     • General Stress Indicator
• Anecdotal information from interviews with
  assessor (LCSW or RN)
• Interview with EPAS Specialist
• Collateral information shared by family,
  caregivers
                                               25
     Cognitive and Behavioral Cuing for
           Daily Decision Making

1.   Decision making and initiation of independent
     living and daily activities
2.   Cognitive remediation: cuing assistance with
     concentrating on specific tasks, memory recall
3.   Behavioral assistance: acknowledgment of
     feelings and cuing with appropriate expression of
     emotions related to passivity and/or frustration
     tolerance
4.   Communication cuing

                                                         26
Decision Making and Initiation
   of Independent Living
     and Daily Activities

•   When to get up to have meals
•   Which clothes to wear
•   Reminder to take breaks at work
•   Reminder to wash hands
•   Reminder to eat meals

                                      27
     Cognitive Remediation:
cuing assistance with concentrating on
     specific tasks, memory recall


•   Reminder to take medications
•   Affirming pill box accuracy
•   Reminder to set alarm
•   Scheduling public transportation and/or
    paratransit

                                          28
     Behavioral Assistance:
acknowledgment of feelings and cuing with
appropriate expression of emotions related
  to passivity and/or frustration tolerance

• Problem solving of coworker
  interactions
• De-stressing of situation
• Reminder to cease inappropriate social
  behaviors

                                           29
    Communication Cuing

• Cuing in socially appropriate verbal
  communication
• Interpretation of actions or intentions
• Debriefing of work relationships




                                            30
       Workplace Examples
Cognitive and Behavioral:
• Stress/communication debriefing
• Discussion of emotional situation
• Prevention of quitting due to frustration
• Managing behaviors and communication

Direct Personal Care:
• Uniform dressing
• Personal hygiene / toileting

                                              31
    Cuing and Reminders
•   Face to face
•   Phone call
•   Text message
•   Watch alarm
•   Email
•   Calendar alarms
•   Other electronic communication

                                     32
 Coordinating Personal
Assistance Services and
Supported Employment

                     Scott Holladay
       Arkansas MIG Project Director
   National Academy for State Health
                    Policy (NASHP)
State Plan PAS Services

   Personal Care (agency services)
       Revised 10/1/2007 to include employment-related
        services

   Independent Choices (consumer-directed)
       Cash-and-counseling model
       Also includes employment-related services




                                                      34
Waiver PAS Services
   PD waiver -- attendant care
       Consumer-directed
       Location not restricted
       Waiver amended to add Buy-In, but not
        implemented yet

   DD waiver – habilitation services
       Location not restricted
       Waiver amendment adding Buy-In pending

                                                 35
Hands-On Care Vs. Cuing

   Personal care – hands-on help for individuals
    with physical dependency need

   Habilitation – teaching, including cuing of
    tasks, but not hands-on help

   DD waiver includes habilitation services, but
    not hands-on care

                                                    36
Supported Employment

   VR and Medicaid supported employment
    were seen as mutually exclusive
   Limited provider networks for both services
   Both services underutilized
   Result: most individuals with DD stuck in
    segregated settings



                                                  37
VR Supported Employment

   VR requires provider commitment to provide
    extended services after closure
   Extended services intended to maintain job
    stability – little funding available
   Individuals with DD may need more intensive
    supports
   VR objected to full-time direct service
    workers (DSW) after closure
                                                 38
Work group examined
support needs

   Cuing
   Communications
   Behavior modification
   Help with ADLs




                            39
Discussion of support needs
paved the way for final agreement

   VR did not object to help with ADLs, or most
    other supports
   VR did object to hands-on help with job tasks
    after closure
   Other parties agreed



                                                   40
Consensus on services &
successful closures:
   Individuals must be able to perform all job
    duties independently at time of closure
   Job coaching fading out
   May still use occasional cuing of job tasks
    after closure, and
   May use full-time DSW for behavior
    modification, communications, ADLs

                                                  41
VR-DD Agreement
Supported Employment
 Phase 1 – VR supported employment from
  assessment thru stabilization and closure
 Phase 2 – Waiver supported employment for
  long-term supports
Other Medicaid supports can be used in either
 phase – personal care, waiver habilitation


                                                42
Advantages

   Meet full range of individual needs
   Serve individuals not enrolled in waivers
   Supplement waiver services with State Plan
    services for additional hours
   More services = more provider agencies =
    more capacity and choice
   Option of consumer-direction

                                                 43
Disadvantages

   Seems more complicated
   More trouble to bill for multiple services




                                                 44
Lessons

   Agencies may use different terminology
   Carefully examine service needs
   Matching service needs with appropriate
    services may help overcome obstacles
       underfunding
       benefit limits
       restrictive service definitions


                                              45
Alternate approach

CMS Core Definition for Waiver Supported
  Employment
The Guidance section states:
 Personal care/assistance may be a
 component part of supported
 employment services but may not
 comprise the entirety of the service.


                                           46
Other disabilities
 Individuals with other disabilities will also
 benefit from coordinating services




                                                 47
For more information:

Scott Holladay
501-682-8510
scott.holladay@arkansas.gov

Betsy Barnes
501-683-6251
betsy.barnes@arkansas.gov


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