National Council on Disability Says Community-Based Services Work: Some States Receive High Marks

8/19/2003

From: Mark S. Quigley of the National Council on Disability, 202-272-2004 or 202-272-2074 TTY

WASHINGTON, Aug. 18 -- The National Council on Disability (NCD) today released a comprehensive, online analysis of federal and state implementation of the Supreme Court's Olmstead decision, saying community-based services work, but more needs to be done.

The report, "Olmstead: Reclaiming Institutionalized Lives" ( http://www.ncd.gov/newsroom/publications/reclaimlives.html ), measures progress to date in the implementation of the landmark U.S. Supreme Court decision in Olmstead v. L.C., 527 U.S. 581 (1999), and related federal and state government initiatives.

Overall, progress to varying degrees has occurred in the implementation of the Olmstead decision. However, given the many areas where progress has not yet been achieved and in recognition of the relatively brief time since the decision was rendered and governmental initiatives were undertaken, it is clear that further efforts are necessary to increase public awareness of Olmstead. It is also necessary to provide education and clarification regarding the applications and implications of the decision to relevant entities, and provide resources necessary to both encourage and to ensure effective adherence to the spirit and intent of Olmstead.

According to NCD chairperson Lex Frieden, "The extent of unnecessary institutionalization of people with disabilities in the United States is daunting. The Olmstead decision has become a powerful impetus for a national effort to increase community-based alternatives and eliminate unjustified institutional placements. Ultimately, only comprehensive amendments to Title XIX of the Social Security Act, similar to the amendments proposed in the Medicaid Community-based Attendant Services and Supports Act (MiCASSA), will overcome the institutional bias within the Medicaid program. Our nation will be much more prosperous when it makes real the right of people with disabilities to live in the most integrated setting," Frieden concluded.

Promising practices in the design, delivery, and financing of community services include:

-- Good practice in Olmstead planning. Indiana's recent plan assigns each recommendation to one of three categories: (1) those that should be implemented quickly and with little or no fiscal impact or regulatory requirements; (2) those that should be implemented quickly but have a fiscal impact or require regulatory changes; and (3) those that are more complex, costly, or difficult and will require more time to develop and implement. Indiana's plan should serve as a model for other states. Nevada's Olmstead plan is commendable for its candid analysis of the state's compliance with Olmstead.

-- Overcoming incentives to unnecessary institutionalization. Examples include Maine's use of pre-admission screening by an independent agency prior to nursing facility placement, Minnesota's legislation encouraging nursing facility operators to take beds out of service, and Washington's system for tracking reduction targets for nursing facility placements.

-- Identification and transition of people with disabilities from institutions. Under contract with the state, disability rights advocates are doing the work of identifying people in nursing facilities who could move to more integrated settings in Colorado and Kansas.

-- Use of trusts and fine funds to finance transition costs and start-up of community services. A creative and underappreciated set of strategies for financing transition costs, providing "bridge funding," and funding new community services involves the creation of trusts and fine funds dedicated to the needs of people with disabilities. North Carolina, Oregon, and Washington have used the proceeds from the sale of state facilities to establish trusts to generate funds for people with disabilities.

-- Housing strategies. Commendably, and in large part because of the influence of the technical assistance provided by the U.S. Department of Health and Human Services' (HHS) Office of Civil Rights, the more recently developed plans tend to reflect the input of housing agencies. Provisions for requiring universal design in new units that state housing agencies fund or finance; ensuring that all existing publicly financed housing has completed Section 504/Americans with Disabilities Act self-evaluations; conducting utilization reviews to ensure that targeted Section 8 programs are fully used; and including home modifications and home repair in the services provided under home- and community-based waivers and independent living programs, are examples of housing-related recommendations in state Olmstead plans.

-- Single point of entry systems. Single point of entry structures have the potential to reduce unnecessary institutionalization by providing easier access to a wider array of community services.

-- Beyond institutional closure: Increasing community integration. Developmental disabilities services in Vermont and New Hampshire show that "the most integrated setting" is more than placement in a residence outside an institution; rather, it is a continuous process of increasing community inclusion. These states' service systems have progressed far beyond institutional closure and are eliminating group homes in favor of living in a companion home or a home of one's own and working at a real job with support.

Based on its research, NCD recommendations for the Federal Government include the following:

-- HHS and the Centers for Medicare and Medicaid (CMS) should provide more explicit guidance on implementation of Olmstead v. L.C.

-- CMS should determine whether the states are adequately identifying residents of Medicaid-funded and -certified facilities that can handle and benefit from community living.

-- HHS should refocus its Real Choice Systems Change grant program as a true system-change project by shifting from funding demonstration projects to funding change that affects entire service systems.

-- HHS should require the states to identify all institutionalized people in the state and their need for community services.

-- CMS should use its waiver approval authority to require the states to minimize "institutional bias" in the choice between institutional and home- and community-based waiver services.

-- HHS should provide federal financial assistance to states to provide small grants to people with disabilities for transition costs from institutions to community.

For more information, contact Mark Quigley or Martin Gould at 202-272-2004.