MINUTES OF THE MEETING OF
THE LEGISLATIVE COMMISSION’S SUBCOMMITTEE TO
STUDY THE STATE PROGRAM
FOR PROVIDING SERVICES TO PERSONS WITH DISABILITIES
February 4, 2002
The second meeting of the Legislative Commission’s Subcommittee to Study State Program for Providing Services to Persons with Disabilities was called to order by Chairman Dina Titus on Monday, February 4, 2002 at 9:41 a.m., in Room 4401 of the Grant Sawyer State Office Building, Las Vegas, Nevada. This meeting was videoconferenced to Room 4100 of the Legislative Building, Carson City, Nevada.
SUBCOMMITTEE MEMBERS PRESENT IN LAS VEGAS:
Senator Dina Titus, Chairman
Senator Raymond D. Rawson
Assemblywoman Vonne S. Chowning
Assemblyman Jerry D. Claborn
SUBCOMMITTEE MEMBERS PRESENT IN CARSON CITY:
Senator Randolph J. Townsend
Assemblywoman Sharron E. Angle
LEGISLATIVE COUNSEL BUREAU STAFF PRESENT:
Bob Guernsey, Principal Deputy Fiscal Analyst, LCB Fiscal Analysis Division
Leslie K. Hamner, Principal Deputy Legislative Counsel, LCB Legal Division
Jo Rasey, Secretary, LCB Fiscal Analysis Division
Exhibit A Meeting Notice and Agenda
Exhibit B Attendance Record
Exhibit C Meeting Packet prepared by Staff
Exhibit D “Medicaid Long-Term Care Expenditures: Nevada,” submitted by Stephen F. Gold
Exhibit E “Study of State Programs for Providing Services to Persons with Disabilities,” submitted by Jo Donlin, and dated February 4, 2002
Exhibit F “The States’ Response to the Olmstead Decision: A Work in Progress,” submitted by Jo Donlin
Exhibit G “Medicaid Long-Term Care Spending for Community-Based Care, FY 1999” postcard, submitted by Jo Donlin
Exhibit H Pre-Publication Draft, NCSL State Legislative Report, “Long-Term Care and the United States Supreme Court’s Olmstead Decision,” submitted by Jo Donlin. This Exhibit was presented to the Subcommittee but not discussed by Ms. Donlin
Exhibit I “An Overview of the Emerging Disability Policy Framework: A Guidepost for Analyzing Public Policy,” submitted by Robert Silverstein
Exhibit J Narrative Outline of the “Emerging Disability Policy Framework: A Guidepost for Analyzing Public Policy,” submitted by Robert Silverstein, and dated August 2000
Exhibit K Home Page of the Nevada Department of Employment, Training and Rehabilitation Website, presented by Myla Florence, and dated January 28, 2002
Chairman Dina Titus called the meeting to order at 9:41 a.m. The secretary called the roll and all members were present.
November 6, 2001 Meeting
Chairman Titus asked for approval of the minutes from the November 6, 2001 meeting, incorporating her comments.
SENATOR RAWSON MOVED FOR APPROVAL OF THE MINUTES FROM THE NOVEMBER 6, 2001 MEETING INCORPORATING CHAIRMAN TITUS’ COMMENTS. ASSEMBLYWOMAN CHOWNING SECONDED THE MOTION, WHICH CARRIED UNANIMOUSLY.
Chairman Titus expressed her appreciation to Michael Willden and Donny Loux for coordinating the schedules of the expert speakers for today’s meeting. She pointed out the speakers’ resumes are included in the meeting packet, Exhibit C, and said they are very impressive. She said the Subcommittee looks forward to determining how it can maximize the efforts of the state in terms of obtaining more funding and in putting that funding to better use as the Subcommittee examines programs for the disabled. Speakers, she said, would be taken out of agenda order to accommodate travel arrangements.
Stephen F. Gold, J.D., is an attorney with the Public Interest Law Center in Philadelphia, Pennsylvania. He specializes in the civil rights of, and represents only, people with disabilities. He represents numerous individuals with disabilities in discrimination lawsuits and represents American Disabled for Attendant Programs Today (ADAPT), the foremost national advocacy organization of people with disabilities. Dr. Gold disclosed he was the arguing attorney for the Helen L. case, which preceded and set the legal foundation for the Olmstead Decision. He has performed a great deal of litigation in disabilities throughout the country. ADAPT representatives, he said, have twice visited Nevada and have provided feedback regarding Nevada and various other states. Prior to the meeting today, Dr. Gold met with a number of Nevada’s disability advocates and was impressed that, unlike many states, there is great unification among people with disabilities, calling Nevada a cross-disability community. Dr. Gold stated he has provided Leslie Hamner, Principal Deputy Legislative Counsel, Legislative Counsel Bureau’s Legal Division, with the citations, references and websites where all data in his presentation can be located.
Nevada, Dr. Gold reported, has made great progress in the last few years. Prior to that, very little progress was made. There is, however, a great deal yet to be accomplished. Problems among states are very similar and many solutions exist. Nevada, he said, is very vulnerable to Olmstead litigation. It is as if Nevada’s “pants are down a little bit,” but there is no need to be sued. He emphasized there are solutions if there is a will. Having tried an Olmstead case in Louisiana and one in Indiana, Dr. Gold stressed Nevada does not want lawyers involved in a lawsuit.
Referring to Exhibit D, Dr. Gold stated that all data was obtained from Health Care Financing and Policy Division (HCFPD) or Medicare. The main source of funding nationally and for Nevada is Medicaid (in his presentation Dr. Gold uses the terms Medicaid and medical assistance interchangeably). Nevada receives a 50/50 federal match. He presented the following data:
1. Medicaid Long-Term Care Expenditures for Nevada
Type of Care 1993 2000 USA – 2000
Personal Care 1% $ 3.0 million ( 1%) 7%
HCBS Waiver 5% $ 19.7 million (14%) 18%
Home Health 5% $ 8.7 million ( 6%) 3%
Nursing Homes 66% $ 86.0 million (59%) 58%
ICF-MR 24% $ 28.5 million (20%) 15%
Totals $112 million $145.9 million
Referring to Item 1 above, Dr. Gold stated there are five long-term care areas involved with Medicaid: personal care, home and community-based waiver (HCBS), and home health, the community-based programs; and nursing homes and intermediate care facilities-mentally retarded (ICF-MR), the institutional-based programs.
In 2000, 79 percent of Nevada’s total Medicaid long-term care expenditures went to institutional care (nursing homes and ICF-MR). Only 21 percent of Nevada’s total Medicaid long-term care expenditures went to community-based, non-institutional services. The largest jump throughout the country is in waiver care. Nevada went from 5 percent long-term care in 1993 to 14 percent in 2000.
Dr. Gold reported that Nevada utilizes the personal care option, but spends only 1 percent of long-term care expenditures on personal care. Some states, such as Louisiana, do not have a personal care option but have increased their waivers. These states realize they can control costs by expanding the personal care option and reducing waivers. The only area where revenue can be realized is from nursing homes and the ICF-MR.
In 2000, Nevada ranked 50th lowest among all states and Washington D.C. in total Medicaid expenditures for long-term care. It ranked 49th in nursing home expenditures, 47th in waiver services, and 39th in ICF-MR.
2. Waivers – 1995 and 2000 Breakdowns
Waivers 1995 2000 % of Total in 2000
MR/DD $3.60 million $13.60 million 69.0%
Aged $3.20 million $05.60 million 28.0%
Aged $0.00 $00.40 million 2.0%
Physically Disabled $0.07 million $00.13 million 0.6%
All $6.90 million $19.70 million
Item 2, Dr. Gold said, shows where waiver money is spent. The waiver program, he said, is related to institutions. A state is not eligible for waiver services unless it is eligible for an institution. In terms of large institutional costs spent on nursing homes, of the $86 million spent in 2000, every individual eligible for a nursing home was eligible for aged and physically disabled waivers. Only individuals eligible for the mentally retarded/developmentally disabled (MR/DD) waivers are eligible for the ICF-MR.
Continuing, Dr. Gold stated that in 1995, Nevada had an equitable distribution of waivers: $3.6 million was spent for MR/DD; $3.2 million for the aged; and $0.07 million for the physically disabled. Most states combine aged and physically disabled because all individuals utilizing an aged waiver must meet the eligibility criteria set for nursing homes. Sometimes, the aged community forgets that in order to be eligible for a waiver they must be disabled. Whatever the age of the disabled individual, they must receive Nevada’s level of care. It is more realistic to combine the aged and the physically disabled waivers. Oregon and Kansas have, over a two or three year period, realized cost savings by diverting people from nursing homes, large and medium sized ICF-MRs, to the community. There are two ways to receive a waiver: an individual can be diverted from entering an institution or that individual can leave an institution. Something psychologically happens to individuals once they have been in a nursing home for two or three months. They become infantile. This is an incredible tragedy, particularly for young women who no longer believe they can function after being institutionalized. Dr. Gold reported he is always amazed at how long it takes to convince institutionalized individuals they can live in the community with supports. The current process required to enter an institution is “helter-skelter.” An individual is placed in a nursing home but Medicaid does not become involved until it begins paying the nursing home bills. The State of Indiana becomes involved before an individual is placed in an ICF-MR or nursing home, the result of which is that the rehabilitation hospital cannot simply “dump” a person in a nursing home. Instead, the individual is offered a specified number of hours of services in the community. A large percentage of people prefer utilizing community services to being institutionalized.
3. Nevada Long-Term Care Expenditure Rankings in 1999 Compared to the USA
· Total Home Health Recipients – 350
Nevada – 0.19 per thousand persons
USA – 314 per thousand persons
Nevada ranked 50th lowest among the states
Nevada expenditures per capita – $1.38
USA expenditures per capita – $8.31
Nevada ranked 43rd lowest among the states
Referring to Item 3, Dr. Gold asked how does Nevada’s Medicaid program compare with the rest of the country? In 1999, only 350 people received home health services in Nevada, less than 0.19 per thousand persons. That compared to 314 per thousand persons throughout the country. Nevada ranked lowest in home health recipients in the country. The state expended $1.38 per capita for home health, while the national average was $8.31. Nevada ranked 43rd lowest in per capita expenditures for home health nationally.
· Total Personal Care Recipients – 491
Nevada – 0.27 per thousand persons
USA – 1.76 per thousand persons
Nevada ranked 24th lowest among the states
Nevada expenditures per capita – $01.34
USA expenditures per capita – $13.45
Nevada ranked 23rd lowest among the states
Referring back to Item 1, Dr. Gold reminded the Subcommittee that in 2000, Nevada spent $3 million, or 1 percent, on personal care. Only 30 or 31 states have a personal care option. In 1999, Nevada served only 491 people through the personal care option. That equates to 0.27 per thousand people. The national average was 1.76 per thousand persons. Nevada ranked 24th lowest of the 30 or 31 states that participated in personal care programs. Per capita, Nevada spent $1.34 compared to the rest of the nation, which spent $13.45. If this area were structured correctly, Nevada could save money. Here Nevada ranked 23rd lowest in the nation.
· Total Waiver Participants – 2,233
Nevada – 1.23 per thousand persons
USA – 2.52 per thousand persons
Nevada ranked 48th lowest among the states
Nevada expenditures per capita – $08.33
USA expenditures per capita – $38.69
Nevada ranked 48th lowest among the states
Dr. Gold reminded the Subcommittee that 69 percent of Nevada’s waiver money goes to MR/DD. Referring to the chart above, he admitted he did not know how many of the 2,233 waiver recipients who received services in 2000 were MR/DD. Nevada served 1.23 per thousand persons, approximately half of the national average, ranking 48th lowest among the states. Nevada’s expenditures per capita were $8.33 as opposed to the national average of $38.69, again ranking it 48th lowest among the states. Many states have developed very creative packages under waivers. Some states include a one‑time transition grant. Some include home modification money for people who must make their homes handicap accessible. Other states utilize State Community Development Block Grant funds. In 2000 and 2001, the U.S. Department of Housing and Urban Development (HUD) issued approximately 144,000 Section VIII vouchers for people with disabilities. This process was competitive and served to remove people from institutions. Dr. Gold explained that if Nevada’s Medicaid personnel were creative, they would coordinate with the housing authority to determine how to spend the 3 percent waiver money received to remove people from institutions. What is important is that this is 100 percent HUD money. A disabled person pays 30 percent of her or his income on housing; HUD pays the remaining 70 percent. This number could go well above 100 or 110 percent of fair market value.
· Total Community-Based Long-Term Care Recipients – 3,074
Nevada – 1.70 per thousand persons
USA – 7.43 per thousand persons
Nevada ranked 50th lowest among the states
Nevada expenditures per capita – $11.05
USA expenditures per capita – $60.45
Nevada ranked 50th lowest among the states
Referring to the chart above, Dr. Gold reported that Nevada has 3,074 community-based long-term recipients. In Nevada, 1.7 per thousand persons receives long-term care, compared to 7.43 per thousand persons in the nation, ranking it 50th in the country. Prior to coming here today, Dr. Gold said he imagined Nevada would be in a much better position than states such as Louisiana, Mississippi, South Carolina, and Georgia, states that are most vulnerable to an Olmstead case. After meeting with Nevada’s advocates and reviewing national data, is appears Nevada is not as well positioned as he had originally believed. Per capita expenditure, Nevada spent $11.05 on community-based long-term care as compared to $60.45 spent nationwide. Here Nevada ranked 50th lowest among the states.
The eligibility criteria for Nevada’s counties should be expanded upon. If Nevada is at 300 percent of Supplemental Security Income (SSI), it can receive waiver services. If, however, it is above that by $1, all social security recipients are above that SSI level. There is a large gap in that only counties can receive institutional care and Nevada is paying that 100 percent with county money.
4. Nursing Homes
Year Number of Beds Number of Residents
1991 2,753 2,471
2001 5,152 4,032
· Between 1991 and 2001, Nevada had an 87% increase in nursing home beds;
· Between 1991 and 1998, Nevada had a 63% increase in nursing hone residents;
· Between 1991 and 2001, there was a 69% increase in nursing home beds in the USA; and
· Between 1991 and 2001, there was a 51% increase in nursing home residents in the USA.
Dr. Gold reported there are two ways to look at Nevada’s nursing home industry. Nursing homes are a business, whether “for profit” or “not for profit.” In Pennsylvania, nursing homes have become the third largest contributor to Tom Ridge’s campaign. This was not what Congress intended in 1967. The nursing home industry has evolved because there is money to be made; the tail is waging the dog.
In 1991, Nevada had 2,753 nursing home beds and 2,471 residents. At the end of 2001, those numbers rose to 5,152 beds with an occupancy rate of 4,032. Nevada is paying for vacant beds. Comparing the growth of the nursing home industry in Nevada from 1991 to 2001, it had an 87 percent increase in nursing home beds and a 63 percent increase in nursing home residents. That is a large increase and is far in excess of the national average of a 69 percent increase in nursing home beds and a 51 percent increase in nursing home residents.
5. 2001 - Nevada
Nursing Number of Number of
Homes Beds Residents
For Profit – Corporation 29 3,708 3,012
For Profit – Partnership 4 677 568
Government – Hospital District 6 154 134
Non-profit – Church 1 16 11
Non-profit – Corporation 5 530 261
Non-profit – Other 1 67 46
Totals 46 5,152 4,032
Referring to the above chart, Dr. Gold said there are 46 nursing homes in Nevada. He did not believe Nevada was paying full rate per bed but was paying for it in terms of capital costs, mortgage, etc. Nevada does not need a 20 percent vacancy rate in nursing home beds. He recommended Nevada “have the money follow the person.” Many individuals are eligible for an institution that do not wish to be institutionalized. Louisiana has redefined its waiting lists. Gaines have been made throughout the country in the disability community from both the consumer’s point of view as well as from the administrator’s point of view regarding waiting lists. Waiting lists are important for good management, but they should not be “scary.” Waiting lists are seriously inflated all over the country. If a disabled individual chooses to live in the community, the state will save money. If the money follows the person, and the money goes out of an institution with the person, the state can decertify nursing home beds. Nevada can live with a 3 percent vacancy bed rate. Decertifying nursing home beds saves money by moving that money into the community. Texas has added a rider to its budget that states that the money follows the person. Missouri budget dictates that the money follows the person. The person has to otherwise meet the level of care in the institution and, Dr. Gold stated, he would like to make it even more restrictive: that an individual would have to be at imminent risk. Most states have very large MR-DD waiting lists. If Nevada had a quickly moving waiting list there would be no need for an individual to purchase an additional insurance policy. The most expensive Medicaid item for most states is nursing homes. That, however, is not true for Nevada. Hospital care is Nevada’s largest Medicaid item. Large numbers of people stay from one to four days beyond which is required because there are no services available for them elsewhere. Nevada is paying hundreds of dollars a day unnecessarily.
6. State Centers
Nevada had a 27 percent increase in state center residents between 1977 and 1996. The USA average was a 60 percent decrease. Nevada was the only state in the nation with an increase.
Continuing, Dr. Gold said state centers are Nevada’s long-term MR/DD. The number of people is not large but it is very surprising. Very few states have had an increase in state centers during the period from 977 through 1996. The United States averaged a 60 percent decrease.
In the rural areas of Nevada, like in Alaska, hospitals are primary employers. Many of Alaska’s hospitals simply keep people because the hospitals need the money; the patients do not need the care. Individuals are also kept in hospitals because Alaska does not have a community-based system for patients. There should be a way to reimburse hospitals for real medical care rather than having them “piggybacked” onto long-term care.
Dr. Gold told the Subcommittee that when the United States Supreme Court ruled on Olmstead, it was a lawsuit waiting to happen. Federal regulations enacted since 1980 had never been enforced until the Helen L. lawsuit of 1993. That case deals with discrimination against people with disabilities. Individuals cannot be discriminated against based on race or gender. Individuals cannot be segregated unnecessarily. The Supreme Court ruled that disabled people must be given real choices. An individual cannot be told that the only choice they have is an institutionalized hospital. They must be given a choice. The simplest method of giving an individual a choice is to have the money follow the individual. A system must be developed for alternate methods of care to allow individuals to continue living in the community in their own homes. It is clear discrimination to unnecessarily segregate individuals. The Supreme Court did not say states could not have waiting lists. They can, but the waiting lists must move at a reasonable pace. States must have a plan that indicates how waiting lists will move at a reasonable pace.
Dr. Gold indicted Nevada has what he describes as a three-year open accordion to increase the number of people placed into the community. After three years it is not expected everyone will be placed or be receiving services. The waiting list must be reasonable as part of the settlement, and he believes 60 days is considered reasonable.
If Nevada has a system in place that interacts with patients at hospitals or rehabilitation hospitals prior to placement in nursing homes, and has contracts in place with independent living centers, it can ensure people are given the community option of where they want to go when they leave. These are the two options: institution or community. It would know what patients want and they could be placed on a waiting list.
Dr. Gold reported there is no requirement under the Americans with Disabilities Act (ADA) to make substantial modifications to a program. That defense is not available to Nevada because Nevada already has a personal care option. Dr. Gold said he did not know how many states have a substantial modification defense. They all have a waiting list moving at a rapid pace defense. Waiting lists can be controlled in terms of decertifying beds and therefore saving money. The American Association of Retired Persons (AARP) does not want their members living in nursing homes. They at least want the choice of living at home versus living in a nursing home.
Chairman Titus thanked Dr. Gold for his presentation, saying the Subcommittee knew the state was in trouble, but the information Dr. Gold presented made that point very graphic.
Dr. Gold assured the Subcommittee he could support the numbers he presented with federal reports provided by Nevada to the federal government, and he could support where Nevada ranks among the other states based on those reports.
Chairman Titus reported she wants to examine the state center increased numbers because she thought Nevada had recently decreased the number of nursing home beds.
The “Braddock Report, State of the States in Developmental Disabilities,” Dr. Gold said, breaks down the ICF-MRs by size. Many states want to move away from the ICF-MR completely and use only waivers because ICF-MR regulations are cumbersome. He reported that a friend of his receives ICF-MR services. She lives alone and three times a week her Intensive Case Manager visits her and they watch television together because ICF-MR regulations require that a Case Manager visit her. The Case Manager gets paid three hours a week to watch television.
Senator Rawson asked if a policy requiring that “the money follow the person” would be catastrophic to the nursing home industry? No, responded Dr. Gold, it could clearly be accomplished with new patients. Currently, Nevada has a 20 percent vacancy rate. Before 1977, anyone with a mental retardation/developmental disability was served only in institutions. Dr. Gold strongly encouraged Nevada to diversify, to let the nursing homes keep the patients they currently have but to mandate that no new individuals be sent to a nursing home without being given a choice.
Jo Donlin, Senior Policy Specialist, National Conference of State Legislatures (NCSL), expressed her thanks at being invited to speak to the Subcommittee. Referring to Exhibit E, Ms. Donlin told the Subcommittee the goals of her presentation would be to summarize the main points of the Olmstead Decision; to review the role of state legislatures in implementing the decision and what it means for state legislatures; to provide a national overview of the states’ response to the decision; to highlight opportunities and challenges; and to summarize the current NCSL activities.
Ms. Donlin reported that the Olmstead Decision ruled that states cannot discriminate against people with disabilities by providing long-term care services only in institutions, when certain individuals could be served in the community. The decision encourages states to re-evaluate how they deliver long-term care services to people with disabilities to determine what changes should be made. The area of greatest confusion regarding Olmsted is who is covered. The plaintiffs did have mental illness and mental retardation so there is confusion that the decision covers only those populations. Because Olmstead was based on the Americans with Disabilities Act (ADA), every individual with a disability is covered by Olmstead. States must comply because Olmstead is a Supreme Court decision.
Ms. Donlin stated three factors must be in place in order for an individual to be placed in the community. The state’s treatment professionals must state it is appropriate; the individual must not oppose the move; and the placement must be reasonably accommodated, taking into account the resources available to the state and the needs of other citizens with disabilities. A key point of Olmstead is that states do not need to “fundamentally alter” their programs. Some of the vague terms in Olmsted will be decided in lower courts as cases are decided in the states.
The Supreme Court, Ms. Donlin continued, offered two ways for states to comply with Olmstead: (1) to develop a comprehensive, effectively working state plan; and (2) to maintain a waiting list that moves at a reasonable pace and is not motivated by a desire to fill institutions.
Ms. Donlin reported there is a great deal of institutional bias even though waivers are in place. The majority of money goes to institutions. In 2000, 73 percent of Medicaid long‑term care dollars across the nation went to institutions, and 27 percent went to home- and community-based services. This takes into account the 250 home- and community-based service waivers.
The most important role of state legislatures, Ms. Donlin said, is to control the purse strings of the various programs. Legislatures must also establish the programs, enact the requirements, and provide the oversight.
Long-term care currently accounts for 35 percent of all state and federal Medicaid funds. Therefore, Olmstead, being a long-term case, will likely affect state budgets. Nationally, 150,000 people under the age of 65 with a variety of conditions and disabilities are currently in nursing homes. Many are there because community-based services are limited. Medicaid pays for the majority of this long-term care. It is important to note that while Medicaid is the focus, other state programs are involved such as housing, transportation, and vocational rehabilitation.
Ms. Donlin drew the Subcommittee’s attention to the National Conference of State Legislatures’ survey completed in October 2001, entitled “The States’ Response to the Decision: A Work in Progress” (Exhibit F). In highlighting the main points of this survey, she said it is very clear that the bulk of the activity has been in the Executive Branch. Forty states plus the District of Columbia have established task forces, commissions or state agency work groups. Governors, legislators, and health commissioners have appointed these task forces, commissions or work groups. Usually, the agency that has played the strongest role is the health and human services agency. Very few have involved legislators. Ms. Donlin noted it has been interesting that people other than legislators have performed most of the activity, but now legislators have to request money or discuss the programs, and many are not even familiar with the word “Olmsted.” Legislators are also dealing on a broad scope, looking at all avenues of what it means to put an institutionalized individual into the community and to implement that adjustment.
Ms. Donlin reminded the Subcommittee that she had previously mentioned that the Supreme Court gives the states the option to develop a state plan. Eighteen states currently have some type of written report or plan (Arizona, Connecticut, Delaware, Georgia, Illinois, Indiana, Iowa, Kentucky, Maryland, Missouri, Montana, North Carolina, Ohio, Oklahoma, South Carolina, Texas, Wisconsin and Wyoming). Ms. Donlin says she uses the words “some type” to describe the written report or plan because the plans vary from a 50-page report to an Excel worksheet. Most plans would not meet the standards that the Centers for Medicare and Medicaid have established for what should be included in a plan. Four states stand out as having a “comprehensive and effectively working” plan: Mississippi, Missouri, Ohio, and Texas. She added that the NCSL website contains links to these state plans. Twelve other states have plans in the works which are estimated to be released in the next six to nine months. It is, Ms. Donlin stressed, important to repeat that states are not required to have a plan. This is a method that states have taken because it is a way to comply with the United States Supreme Court and it is what they have looked at. Some states have been doing other things rather than developing a state plan.
Ms. Donlin listed recommendations some commissions have made, indicating they cut across many different areas:
To date, there has been little legislative activity directly in response to Olmstead, but many states are looking at long-term care legislation and making some changes. It is interesting to track legislation because legislation is made in many different areas and the decision cannot simply be searched under “Olmstead.” Missouri has enacted a wage pass-through for MR/DD caregivers; funds for training staff and individuals; money for transition costs; and has added a personal care benefit to its Medicaid plan. Maryland has expanded its waiver to 300 percent of the SSI eligibility level. Texas has expanded all six of its waiver programs. Last year, Nevada approved funding for independent living assistance for people with disabilities and expanded by 88 percent its home- and community-based waiver services for people with physical disabilities.
This year will be a challenge for states. Olmstead has received a lot of momentum since September 11th, and legislators and legislatures are looking at different methods of implementation. The economy is very different than prior to September 11th. Therefore, many state plans will be presented during the 2002 Legislative Sessions, but with the economy, budgets and terrorism, state legislatures’ focus may not be as much on Olmstead as it was nine months ago.
Many challenges face the states:
· Budget shortfalls. Forty-three states have reported budget shortfalls to NCSL and thirty-six states are considering budget cuts or holdbacks. Eighteen states have Medicaid overruns and others are very concerned. Medicaid is a difficult budget issue and many states are examining it;
· Housing remains a challenge. Some states utilize Section VIII vouchers but housing remains very expensive;
· Workforce shortages;
· Transportation; and
· Data collection and the ability to track individuals to determine who needs services.
Many opportunities face the states:
· Everyone is involved and working together. The effort is very cross-agency. Many people are working together who have never before worked together;
· The federal government is helping:
- The Centers for Medicare and Medicaid Services (CMS) has issued five guidance letters (accessible on the NCSL website);
- A $70 million “Real Choices Grant” program was initiated;
- Nevada received a $655,988 Community-Integrated Personal Assistance Services and Supports Grant. Not all states received grants;
- $5 million was given by the United States Department of Health and Human Services (HHS) to the National Technical Assistance Exchange for Community Living;
- In June, President Bush issued an Executive Order that asked federal agencies to examine their policies and procedures to assist with a quick implementation of Olmstead. That report was released in December and involved HHS, the Department of Labor, and HUD; and
· All these federal programs have been part of President Bush’s “New Freedom Initiative” which is the Administration’s policy on removing barriers to equality for 54 million Americans living with disabilities.
Ms. Donlin stated that NCSL is in the early stages of implementing Olmstead. States are just beginning to take their plans to their legislatures. NCSL will continue to educate legislatures about Olmstead through publications, meetings, and an up-to-date website. They will track state plans and legislative activity, and will provide technical assistance to states and to advocacy groups to enable them to work better with state legislatures.
Ms. Donlin concluded her presentation by giving the following resources for assistance:
· The NCSL website (http://www.ncsl.org/programs/health/disabil2.htm). Here NCSL links to many other websites of interest;
· The Centers for Medicare and Medicaid Services (http://www.hcfa.gov);
· The National Technical Assistance Exchange. Two organizations received the $5 million grant:
- Susan Reinhard, Rutgers University, Center for State Health Policy (732 932-3105, extension 230); and
- Richard Petty, Independent Living Research Utilization (713-520-0232); and
· NCSL Advisory Group (a list of approximately 120 legislators in various states who are interested in or dealing with Olmstead).
Chairman Titus thanked Ms. Donlin for her excellent presentation.
Senator Rawson asked if any states have found the ideal method to deal with Olmstead.
Ms. Donlin responded there is no “cookie cutter” plan. Once a state gets beyond simply providing services, much larger issues surface such as housing and transportation. Every state has different budgetary situations and different sized waiting lists. She referred to Exhibit G, the “Medicaid Long-Term Care Spending for Community-Based Care, FY 1999” postcard. Much variation exists across the nation regarding where states spend their Medicaid long-term care dollars.
Chairman Titus told Ms. Donlin that her description of the new priorities for the upcoming Legislative Session and the problems concerning economics and the Medicaid budget hits home for Nevada and it is discouraging.
Assemblywoman Chowning remarked it is discouraging to hear that Nevada is at or near the bottom of the lists in so many areas. Some programs that Nevada has implemented have not caught up to the statistics. A fixed route transportation system has been in existence for some years whereby people are picked up at their homes and taken to training centers. Many people now are gainfully employed as a result of the legislation passing Medicaid reimbursement. Assemblywoman Chowning expressed her appreciation for NCSL’s participation in today’s meeting, saying there have been many times that NCSL has been helpful with legislation on issues in other states and because of NCSL’s analysis. She asked for NCSL’s assistance to help Nevada get to the top of the lists instead of the bottom.
Ms. Donlin assured the Subcommittee they could call on her at any time for assistance with a particular idea. Each state is so individualized that little things are making a difference. North Dakota, for instance, struggles because it is so rural it is difficult to get services and transportation to many of those rural areas.
Robert Silverstein, Director of the Center for the Study and Advancement of Disability Policy (CSADP), spent 10 years as the Staff Director and Chief Counsel to the United States Senate Subcommittee on Disability Policy. Prior to that he was Counsel for the United States House Subcommittee on Select Education. These subcommittees had jurisdiction over many major disability programs including the Americans with Disabilities Act (ADA), the Rehabilitation Act, the Individuals with Disabilities Education Act, the Developmental Disabilities Act, and the Technology Act for People with Disabilities. Of the 20 pieces of legislation he worked on, all were bipartisan. There were no votes in committee on any bill; all were unanimous. CSADP, among other things, tries to provide technical assistance to people concerned with enhancing opportunities for individuals with disabilities.
Mr. Silverstein reported he had examined the various federal laws that deal with people with disabilities to determine if a common set of themes, principles, values, or policies cut across all the legislation. This was to determine if a framework could be developed as a way of assessing how we, as a society, are meeting the needs of people with disabilities. “We,” he said, could be the state legislature, the executive agency, or the community rehabilitation provider.
Mr. Silverstein told the Subcommittee that Appendix 1 of Exhibit I, “An Overview of the Emerging Disability Policy Framework: A Guidepost for Analyzing Public Policy,” is a narrative outline of the 60-page article on the Emerging Disability Policy Framework. In the narrative outline he identifies major issues contained in the original article. After describing the framework, he says he developed a series of 30 to 40 questions which are effectively the disability audit, or, in Nevada’s case, an outline for a comprehensive effective working plan for implementing Olmstead. Exhibit J, Mr. Silverstein added, is a PowerPoint presentation which he will use for his presentation today.
Mr. Silverstein said that when he worked in Congress the first thing his members wanted to know was the historical context. Why is legislation necessary and why are specific kinds of legislation or policy needed? In the case of Olmstead, it is critical for people to understand the old paradigm for dealing with people with disabilities. Professionals and policy makers historically viewed people with disabilities as “defective and in need of fixing.” If a person with a disability could not be “fixed,” the professionals felt there was a failure and, as a result, there was exclusion, segregation, and denial of services. Mr. Silverstein gave the following examples of how professionals and policy makers dealt with people with disabilities:
· Ugly laws existed in the United States that stated that if a person with a certain kind of deformity appeared in public, that person was subject to a fine. Ugly laws were on the books in Chicago until 1975.
· Prior to 1975, many states gave authority to school officials to totally exclude children with disabilities if, in the words of Maine’s statute, it was “inexpedient” to serve them. The Wisconsin Supreme Court issued a ruling that was the law of the land until the 1970s that dealt with a child with cerebral palsey. The Supreme Court ruled the school system could totally exclude that child because he produced a disgusting and “nauseating” effect on other children and teachers.
· Justice Oliver Wendell Holmes dealt with a case of whether or not a woman with mental retardation could be forced to be sterilized. His conclusion was “yes,” that individual could be sterilized because society must ensure it can “extinguish the race” of people with this kind of condition.
· In the early 1910s through the 1930s, many professionals and policy makers formed commissions which wrote reports that concluded that people with developmental disabilities were a “menace to society,” responsible for many, if not all, social ills.
Mr. Silverstein stated the reason he began his presentation with examples of the old paradigms is that it must be understood that when society moves from an old approach to a new approach all the systems and attitudes do not necessarily move. Beginning in the 1970s and culminating in 1990 with the enactment of the Americans with Disabilities Act (ADA), the country rejected the old paradigm. Society realized it needed to focus on a different premise and that premise was that disability, like race and gender, is a natural and normal part of the human experience that in no way diminishes a person’s right to fully participate in all aspects of society. What society should focus on is fixing the environment, not fixing the individual. From this, four goals of disability policy were developed. These goals are articulated in the ADA. They are not the goals of ADA per se, but the goals of all our nation’s policies with respect to people with disabilities.
Mr. Silverstein asked if Nevada is going to prepare a comprehensive effective working plan, what will the vision be, where are the guiding principals, and where are the decision rules for deciding what to do and what not to do. Mr. Silverstein stressed he will review Olmstead through those principals, that vision, those values, those decision rules that should guide any comprehensive effective working plan that the United States Supreme Court decision discussed. It is a framework, a checklist. The goals of disability policy are:
· Equality of Opportunity
- Individualization – Treat a person based on facts and objective evidence, on their interests, concerns, priorities, preferences and capabilities, and not based on fear, ignorance, prejudice or labels.
- Genuine, Effective and Meaningful Opportunity – Provide reasonable accommodations, make programs accessible, and make reasonable modifications to policies. Mr. Silverstein asked the Subcommittee to imagine that this meeting room had no lights or audio-visual equipment and that every one was asked to stand for the duration of the presentation. The communication and the exchange would not be as great if we were in the dark, with no amplification, and if we were standing. Yet, these amenities are taken for granted because there are accommodations and meaningful opportunity for the average person. The disability policy framework states that if everyone is invited, all means all, and everyone should have genuine, effective and meaningful opportunity. Consider, he said, the cost to wire this building in order to provide amplification and lights. However, an extra charge is not made for those who need amplification and lights. That is what providing meaningful opportunity means. That is what is meant by having interpreters, materials in alternative formats, physically accessible buildings, special education and related services, and reasonable accommodations for employees: doing reasonable modifications to policies. This is a very critical component of a comprehensive effective working plan.
- Inclusion and Integration – In order to receive state-provided good service or support, should an individual be asked to give up their right to interact with non-disabled persons? Should they be unjustifiably and unnecessarily isolated and segregated in order to receive a service, a benefit, or a support? This principle is very important. There is a strong presumption in federal law that disabled people should receive services in the same setting as non-disabled people to the maximum extent appropriate. The burden of proof is on the state to demonstrate why services in the most integrated setting are not possible.
· Full Participation – People in the disability community use the phrase “nothing about us without us.” That means that decisions that impact people with disabilities and their families should be made with those people center-stage in making the decision, not professionals telling people what the right answer is, or imposing their will on people with disabilities. The concepts of self‑determination, person-centered planning, self-advocacy, informed choice, and real choice are the cornerstones of disability policy. That is why it is critically important that cross-disability groups be involved in comprehensive working plans.
· Independent Living – It is legitimate for policy makers to ensure that the policies, practices, procedures, services and support lead to independent living as opposed to dependency. Disabled people need independent living skills in order to live in the community. They need long-term services and supports, including personal assistance, services, and assistive technology. Sometimes they need cash assistance.
· Economic Self-Sufficiency – Another legitimate outcome for policy makers to remember is that people can and want to work. Policies should be made that support increased levels of economic self-sufficiency including work incentives and Medicaid buy-ins.
Mr. Silverstein asked how we determine ways that facilitate rather than impede achieving these policy objectives? This is where the comprehensive effective working plan comes in. Listed in Mr. Silverstein’s exhibit is a series of items under “Methods of Administration” which translate more specifically in terms of developing the framework of a comprehensive effective working plan. He asked the Subcommittee to think about the words of the Supreme Court and how important they are: “comprehensive” as opposed to “silo.” This is not education, labor, health care and housing. It states a “comprehensive effective working plan.” It is not an idea of something in the future; it is something that is real, specific, immediate, realizable, and actionable. The ADA regulations bring to life methods of administration, which are systems change. It states that methods of administration must facilitate, not defeat or substantially impair, the objectives of a state’s program.
Mr. Silverstein asked what are the “objectives” of a state program? A program should reflect the new paradigm of disability policy. It should include health care, long-term services, and support designed to address the unique needs of the individual. It should provide meaningful and effective interventions, services and support. It should be administered in the most integrated setting appropriate to meet individual needs to the maximum extent appropriate and in inclusive settings. It should ensure self‑determination, person-centered planning and real choices. It should provide cross‑disability participation at the systems level which should result in independent living and economic self-sufficiency.
Mr. Silverstein continued stating that the next component of a comprehensive effective working plan is to do a review. Review the vision that guided the policies in the State of Nevada up to this point, both historically and more currently. What are the regulatory provisions, the policies, the practices, and the procedures currently in place? Perform an historical review to determine if they facilitate or if they impede achieving the objectives described above. Examine how programs are administered in Nevada. Does Nevada have silos? Do the housing silo, transportation silo, cash assistance silo, employment silo, community services silo, institutional placement within long-term services and support silo, and the health care silos speak to one another? What are the guiding principles? What about training and staffing, and the finance systems? Does Nevada have an institutional bias? What kinds of budgets are in place? What kind of outcome performance measures are used in this era of performance outcomes? What standards does Nevada use? Are they the standards described here? Does an individual have a choice? Is there a strong presumption of providing services in the community, or does Nevada simply measure the number of open beds?
After performing a review to determine where Nevada is in terms of the relationship between methods of administration and principals or objectives, try to determine the specific steps to take to change those policies, practices and procedures that are not specifically designed to achieve those objectives. If Nevada finds these systems do not support these objectives, it might need to take additional steps that specifically address the historical denial of services. If Nevada is trying to eliminate the silos and recognize the fact that people with disabilities have multiple problems and barriers they face in order to live in the community, it needs to have a comprehensive plan that is person‑centered, that focuses on the individual, not the jurisdiction of the subcommittee, not the jurisdiction of the department, but focuses on the individual as the center of the policy to address that person’s needs. Timelines will be required if Nevada is to prepare a comprehensive effective working plan. Budgets, finance schemes, quality assurance, staffing and outcome performance measures will have to be examined. If Nevada is to prepare a comprehensive effective plan it will have specific policies for transitioning people from institutions to the community, and not expect to write a policy and then suddenly have institutionalized people move to a community.
Nevada will need diversion programs of the kinds that the previous speakers spoke about today. Diversion in the sense that instead of sending an individual to an institution in the first place, systems would be in place to provide services in the community. There would be outreach to people to let them know what is happening. Nevada would have advocacy support so the independent living centers and other groups would have the knowledge, the understanding of what individuals’ rights are. They would know what the system is supposed to do, and would help educate people in the community as to what their rights are. Nevada would have a due process procedural safeguard for individuals. And Nevada would strive to ensure the programs it provides are state-of-the art. In a nutshell, the federal government has developed a framework it hopes can be useful to assist Nevada in developing its comprehensive effective working plan for implementation of Olmstead.
Chairman Titus thanked Mr. Silverstein for his excellent presentation. She said one thing Nevada has encountered is that the legislature tends to blame the bureaucracy for being inefficient, the bureaucracy blames the legislature for not giving them enough money, and the public simply blames government in general for not getting the job done. That is one reason this Subcommittee is trying to work with the Executive Branch. As Michael Willden reported at the November 6, 200 meeting, Nevada is trying to bring everyone to the table; and as Ms. Donlin pointed out, that is both a challenge and an asset as Nevada works toward doing away with silos. It is not an easy task.
Mr. Silverstein concurred with Chairman Titus, adding it is important that everyone sees this new paradigm and uses it to test each and everything that is done. When taking certain steps, ask if those steps further the goals. The simple notion that the core of this is a strong presumption that people should receive long-term services in the community turns the whole system upside-down. If the system now is 80 percent in institutions and a survey is performed of what people want, and 80 percent of the people want community services and supports, then the question becomes, how do you develop these methods of administration to change that paradigm, to change that system so it reflects what people want. Sometimes that takes money. Sometimes it takes administrative will. It is hard work to cut across silos. It is so much easier to simply say it is a cost issue and cannot be done when, in fact, there is so much that could be done in terms of administration.
Chairman Titus said it is also important to know what services are currently available, who receives those services, and then to move toward one-stop shopping in order to make distribution of information more effective and efficient. She asked what other states have done regarding devising a tax policy for providing incentives to employees. She thanked Mr. Silverstein again for his presentation.
Mr. Silverstein reported there are provisions in the ADA to provide tax incentives for hiring people with disabilities. A number of states have enacted similar kinds of legislation. When we talk about Olmstead, we are not simply talking about long-term services and supports. We are talking about employment, transportation, housing, and income assistance programs. We are talking about a way of pulling things together so that the person is in the middle of the policy. We are talking about developing that comprehensive approach that recognizes the multiplicity of barriers that individuals face and that we, as a society or as policy makers, do not create additional barriers given the complexity, the silos, and the different eligibility criteria. When Secretary Thompson issued a report to President Bush on Olmstead implementation, he found the number one barriers were the lack of collaboration, coordination, policy, and implementation among federal agencies.
Assemblywoman Chowning reported that Nevada recently imposed that agencies incorporate outcome measures as a requirement in their budgets. It is now standard procedure that when budgets are presented members of the money committees review those outcome measures. She suggested the Subcommittee implement the ideas and suggestions presented by the speakers today.
Senator Rawson reminded the Subcommittee that a hiring freeze has been in effect for six of the last ten years. Agencies must simply “roll their eyes” whenever they hear the Legislature is even looking at a new program or at a new way of doing things. That has to be part of the inertia that must be overcome. If Nevada is going to change, it must address the personnel issues and give agencies what they need to deal with the change.
Myla Florence, Director, Department of Employment, Training and Rehabilitation (DETR), informed the Subcommittee that Tab VI of the meeting packet provides most of the information she would review. She referred to Exhibit K, the DETR website, saying it is a rich resource of services provided by DETR.
The major programs within DETR that provide services to individuals with disabilities are administered through the Rehabilitation Division. Page 37 of the meeting packet contains the information on the Rehabilitation Division:
· Bureau of Vocational Rehabilitation (BVR) – This Bureau determines eligibility for individuals with impediments to employment by trained vocational rehabilitation counselors. The program is funded 78.7 percent by the federal government, requiring a state match of 21.3 percent. The total program is approximately $14 million each year of the biennium. A little over $6 million is allocated toward client services with most of the balance used for staffing. There are 66.51 full time employees providing services through this program. In addition to the direct services provided by counselors, DETR contracts with many community-based organizations. At the end of state fiscal year 2001, 3,109 people were still being served within the program and throughout that period, almost 6,400 individuals were served. Services are targeted to the more severely disabled with 85.7 percent of the individuals served having severe disabling conditions. Ms. Florence pointed out that Page 40 of the meeting packet lists the types of conditions individuals have who are served by the program. Generally, individuals have more than one disabling condition. The majority of these conditions are mental dysfunctioning, orthopedic, mental, and central nervous conditions.
Page 41 of the meeting packet lists a breakout by race, Hispanic origin, gender, and age of the 6, 387 individuals served. Most noticeable is that approximately 78 percent of the population served is between the ages of 20 and 49. The thrust of this program is to move individuals into employment and these age groups are typically associated with individuals either moving in the workforce or currently seeking work.
Typically, the source of referral of individuals comes from the medical community and individuals who have been served by the program. Almost 15 percent of referrals come from other individuals. Approximately that same percent comes from educational institutions. The program strives to make the school-to-work transition known to individuals coming out of high school or connecting with the university and college system for individuals who may need support in terms of accessing the educational community.
Pages 42 through 44 of the meeting packet indicate the kinds of services available under the Rehabilitation Act. Any need identified in an individual’s plan to enable them to remain in or to return to the workforce is provided by BVR. It is important to note that while monies are appropriated to these programs, there is an economic gain to the citizens of Nevada. In SFY 2001, 885 individuals returned to competitive employment and generated an annual estimated earning of $17,119,440. That number was calculated based on their earnings as reported at the time of employment. Twenty-two individuals were assisted in self‑employment opportunities. An entire new wave of entrepreneual opportunities exists, particularly for individuals with disabilities who, with adaptive equipment, may start a home business. Eighty-one individuals returned to competitive employment and were removed from the Social Security Disability Insurance (SSDI) program, saving approximately $3,150,720 in on‑going Social Security payments. BVR estimates that for every dollar spent, $5 is saved in reduced future benefits.
· Bureau of Services to the Blind and Visually Impaired (BSBVI) – This Bureau is authorized under the Vocational Rehabilitation Services Act and provides many of the services provided by the BVR; however, they are targeted to blind individuals or to individuals with severe visual impairments. The program provides assistance with low-vision examinations, mobility training, evaluation, life skills evaluation, and assists individuals by installing identifiers on kitchen cabinets to assist a visually impaired person maintain themselves within their home. This program is funded 78.7 percent by federal funding under the Rehabilitation Services Act, and 21.3 percent by state funding. Life skills training is funded though State General Funds at approximately $35,000. There are 23.5 individuals providing direct services within this program with a budget of $3.9 million each year of the biennium. During SFY 2001, 527 individuals were served, with 302 individuals still receiving services at the end of SFY 2001. Demographics of the individuals served do not totally reflect the demographics of Nevada. Outreach efforts have been initiated to better serve the Hispanic and Black communities within Nevada. The program assisted 84 clients in entering non-competitive employment and generated $1,953,370 in earnings on an annualized basis. Five individuals moved from Social Security into competitive employment, saving the Social Security Administration $169,605 in future benefit payments at a cost to the program of $33,921.
· Business Enterprises of Nevada (BEN) – This program is authorized under the Randolph-Sheppard Vending Stand Act which provides placement and management services to legally blind individuals who operate food service and vending stands within public buildings in Nevada. While this program is authorized under the Randolph-Sheppard Act, the state also implemented a mini‑version of the Randolph-Sheppard Act, which principally refers to federal sites, whereas NRS 426 relates to state, county and other municipality buildings within Nevada. The program is approximately $1.8 million with 5.5 full time employees allocated to it. The program provides for 25 vending facilities in Nevada operated by 21 licensed operators. It generated gross sales of $8,795,429, and resulted in an average net profit to operators of $76,605. More importantly, it has provided employment opportunities for other disabled individuals. A total of 143 people are employed within this program. It is completely self-reliant in terms of funding; there are no state or federal appropriations. Profits to the vendors are reinvested back into the program and provide for additional training opportunities for individuals who may be referred to the program.
· Bureau of Disability Adjudication – This program provides medical determinations only for Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) benefits. People applying for this program must apply at the Social Security Administration office. At the time the Social Security Administration determines a person is eligible under the qualifying conditions, that medical determination is sent to DETR. Budget for this program is approximately $8.2 million and 68 individuals are employed. In FFY 2001, the Bureau received 18,887 cases and issued 20,405 claims. The Bureau is proud to report that while there often is concern about timeliness with this program, the productivity indicators for the staff, along with case accuracy of determinations, are among the highest in the nation. Nevada ranks in the top three to five in the nation. Nevada has almost as many cases coming in as it has going out. The program, therefore, is federally funded and the number of staff is dependent upon resources the federal government provides.
· Office of Community Based Services (OCBS) – This office supports services leveraged with community-based organizations and continuously seeks new funding opportunities. Through the efforts of Donny Loux, Chief of OCBS, in collaboration with other partners in the Department of Human Resources, Nevada aggressively pursues grant funding opportunities provided by the federal government. A biennial budget of approximately $1 million provides personal assistance services through contractors, telecommunications devices, independent living services, housing services, dental services, assistive technology, deaf resources, information, and referral services. The funding provided by OCBS often acts as seed money to leverage additional resources.
Chairman Titus stated that the Subcommittee has heard about the importance that waiting lists move rapidly, that there be coordination with other agencies, that there be more outreach, and that the state try to receive more federal money. She asked Ms. Florence to address these points.
Ms. Florence responded that waiting lists sometimes do not tell the entire story. The facts are either over-stated or under-stated. DETR keeps records, particularly in the area of personal assistance and independent living services. A one-time appropriation was approved last Legislative Session that addressed the waiting list for independent living services. The issue of how much money is needed to deal with waiting lists varies from day to day. We have heard this morning that as long as Nevada can demonstrate a reasonable method and effort to address waiting lists, the state would be fulfilling the requirements of the Olmstead Decision.
Chairman Titus asked if Nevada has a graduated waiting list where individuals move from one list to another, depending on changing circumstances. Ms. Florence responded she did not believe Nevada has priorities on its graduated waiting lists. In some extreme cases an individual may move up on a waiting list, but she pointed out that those are hard calls to make.
Chairman Titus inquired if DETR coordinates with other agencies that deal with problems associated with the disabled. Ms. Florence responded that Nevada is very fortunate in that it is still small enough that the same parties are interested in the same issues and Nevada has a good communication structure. The Office of Community Based Services has a strong relationship with Medicaid, Aging Services and Mental Health, and tries to utilize the limited funding available in Nevada in the most efficient way so as not to duplicate services.
When Chairman Titus asked about the concept of one-stop shopping for disabled individuals who need these services, Ms. Florence responded it would be difficult. Nevada has done an excellent job of developing a network of services for seniors. In almost every community there are green signs that announce senior centers. However, seniors say they do not know where to go for information. The concept of one-stop shopping is important, but will never fulfill the informational need. Anything Nevada can do to co-locate services in a community with heightened marketing and communication will help.
In response to Senator Rawson’s question about what Nevada is providing for the individual who has never been in the workforce, Ms. Florence responded that Vocational Rehabilitation counselors are working with school districts prior to graduation to discuss transitional issues and services available within the Bureau of Vocational Rehabilitation Services. During the last Legislative Session, a position was funded in the Bureau of Services to the Blind and Visually Impaired for a Transition Coordinator to work with that population. That position has not yet been filled due to the current hiring freeze to which Senator Rawson responded that health and safety issues are some of the exemptions he understood Governor Guinn would examine on a case-by-case basis. He asked if Nevada uses the same technology generally accepted and used in other states. Ms. Florence responded yes, to the extent of the resources. Most people within Nevada know the realities of the economics and try to choose the assistive technology that works within those funds.
Chairman Titus thanked Ms. Florence for her presentation.
Update of the
Development of Strategic Health Care Plans by the
Department of Human Resources
Michael J. Willden, Director, Department of Human Resources (DHR), testifying from Carson City, stated that Tab VII of the meeting packet contains the information provided by his Department. He said the following items would bring the Subcommittee up‑to‑date on the activities of the Strategic Planning Workgroup since the November 6, 2001 meeting:
· The Department of Human Resources issued a Request for Proposal (RFP) for independent contractors to assist with the development of the strategic planning process. Those RFPs were let on September 24, 2001.
· Six bids were received for consideration:
- EP&P Consulting, Inc. (Gretchen Engquist)
- The Lewin Group (Charles Milligan)
- Love “N” Care Inc. (Ophelia Simmons)
- McManis Consulting (Keith Moore)
- The Rensselaerville Institute (Denise Klein)
- Walter McDonald & Associates, Inc. (Walter McDonald)
· The bid/contract was awarded to The Rensselaerville Institute (TRI) for a total contract amount of $263,440. Project completion is established at September 30, 2002. Specific project deliverables were identified as a part of the contract and are listed on Page 77 of the meeting packet.
· On December 11, 2001, Carson City, the Carson City Mental Health Coalition, Carson Tahoe Hospital, Behavioral Health Services, and DHR hosted a project kick-off meeting in the Carson City legislative building. This meeting was the first opportunity for contractors to be introduced and for everyone involved in the planning project to meet informally and exchange ideas. The kick-off meeting was very well attended.
· Preliminary meetings with contractors, DHR staff, and task force coordinators and chairs were held in December 2001.
· On January 7, 2002, a conference call was held with contractors to discuss the revised list of deliverables and the reimbursement schedule. The primary changes made were to add outcome/vision and values/key belief statement as front-end deliverables and to revise the payment structure to be “deliverable based” to allow for cash flow to the contractor. The contract amount remained at $263,440, contrary to information reported on Page 73 of the meeting packet.
· Meeting schedules and focus groups were established for the next eight months.
· The Strategic Plan Steering Committee met on January 23, 2002 to review the plans for each contractor (Rural Health, Rates, and Seniors/Disabilities) and to provide project direction.
· TRI provided training to the People with Disabilities Task Force on January 25 and to the Seniors Task Force on January 24 regarding the TRI planning approach.
· Monthly progress reports will be provided to DHR and project deliverables will be closely monitored.
· On December 17, 2001, key members of DHR, DETR/OCBS, the Attorney General’s office, the Legislative Counsel Bureau, legislators, and task force members received invaluable training on issues and requirements thanks to OCBS and the Centers for Independent Living.
· The DHR Strategic Planning website continues to be updated frequently and remains an excellent tool for communication and to keep up-to-date on scheduled meetings, minutes, and project progress.
Page 83 of the meeting packet lists the revised deliverables and the reimbursement schedule. A schedule of work to be performed by the contractor over the next few months is shown on Page 95. If this Subcommittee is interested in talking with the contractors it can consult those dates. On January 23, the Strategic Planning Steering Committee and staff met to hear reports from various contractors. There was concern from the Steering Committee that the Disabilities presentation was more general than the Steering Committee wished. We need to make sure the contractors are on task providing the deliverables contracted for. A copy of the contractor’s presentation is included in the meeting packet beginning on Page 145.
The Steering Committee will meet again in March or April to continue monitoring the progress of the various contractors and work groups. TRI, the Disabilities contractor, provided two training sessions on January 24 and 25 regarding senior and disability issues as part of their orientation process. Monthly progress reports and project deliverables from the contractors are required, specifically with regard to the disabilities and seniors contractor. The schedule of deliverables is contained on Pages 88 and 89 of the meeting packet.
Mr. Willden expressed his thanks to the Office of Community Based Services, Donny Loux, and the Centers for Independent Living for sponsoring the Olmstead training held in Reno for members of DHR, DETR, the Attorney General’s office, members of the LCB, and others.
Mr. Willden reminded the Subcommittee that DHR continues to use its website to keep everyone informed. Through it individuals can continue to monitor the progress of the task force, review minutes, schedules, and documents produced.
Chairman Titus thanked Mr. Willden for his presentation, adding that she especially appreciates that he works with and keeps the Subcommittee up-to-date. She added it is important that the task force provide this Subcommittee with its recommendations before its final meeting in order to have those recommendations drawn up into a bill draft or resolution prior to next session.
Chairman Titus also expressed thanks to Donny Loux and George Brown, Chairman of the Nevada Counsel on Developmental Disabilities, who arranged for the excellent speakers today.
Tina Schafer, from Las Vegas, emphasized that without transportation to work, all that has been discussed today is of no avail. Her experience has been that the Las Vegas Paratransit is not conducive to assisting the disabled get to work. She told the Subcommittee of a young mildly retarded man with a graveyard job at the MGM Grand. As a result of Paratransit deciding he was not eligible for their services, this young man has to take a bus and cross a four-lane highway late at night. She personally had been told she is not eligible because she can use fixed service once the streets are ramped. Transportation should be a service that is considered in assisting persons with disabilities.
Chairman Titus responded that transportation has been mentioned as one of the goals Nevada needs to examine.
Mary Evilsizer, Executive Director, Southern Nevada Center for Independent Living, expressed her thanks to the Subcommittee for listening so enthusiastically to the speakers today. One of the challenges at the Center for Independent Living is transitioning from the institution to the community – this is the number one fear factor. When an individual ends up in an institution, all systems have failed that individual. To try to encourage an institutionalized individual to transition into the community again without resources and systems would be like setting them up for failure again. She stated that Dr. Gold made three points that would help Nevada: (1) the controlled lists; (2) have the funding follow the person; and (3) utilized diversion where no new person enters a nursing home. Perhaps the best way to implement these is to analyze what we have and review what we need. She recommended Nevada look at how Texas has handled the implementation of their Olmstead plan.
The next meeting of the Subcommittee is tentatively scheduled during the last week of March 2002.
There being no further business before the Subcommittee, the Chairman adjourned the meeting at 12:37 p.m.
Senator Dina Titus, Chairman
Copies of exhibits mentioned in these minutes are on file in the Research Library of the Legislative Counsel Bureau, Carson City, Nevada. You may contact the Library at (775‑684-6827).