building on abilities Designing Supports Budgets Based on

building on abilities Designing Supports Budgets Based on Assessed Supports Needs December 2015 John Agosta Jagosta@hsri. org Megan Villwock Mvillwock@hsri. org Human Services Research Institute 7690 SW Mohawk Street Tualatin, OR 97062 +1 503 -924 -3783 www. hsri. org STRENGTHENING CLDS 1

Introductions ◦ Vulnerable Persons Act & driving principles Today’s Agenda ◦ Project intentions Data presentation and analysis ◦ General approach ◦ Supports needs assessment ◦ Level assignment ◦ Support needs by level by residence and spending ◦ Focus on people living home with family Next steps Questions and discussion STRENGTHENING CLDS 2

Manitoba Family Services Departmental Vision Manitobans with developmental disabilities are supported to achieve their fullest potential through inclusion in society, in economy, and in the labor market. STRENGTHENING CLDS 3

VPA Philosophical Framework • Individuals with Disabilities should have the opportunity to: § Lead satisfying, productive lives in their communities. § Make their own decisions & direct their own lives, with support if necessary. § Take risks that they & their support network deem appropriate. § Use services that are available to all members of society with adaptation & support where possible. § maintain family bonds & develop relationships that are a natural part of life. • Supportive & protective services for individuals with disabilities should be individualized, community based & non-segregated. • When individuals are vulnerable & at risk of suffering harm to themselves or others, their rights & freedoms must be respected & the least restrictive form of support used. STRENGTHENING CLDS 4

Blending Together Principles Related to Service Delivery & System Management Services & supports that people with intellectual and developmental disabilities prefer A personcentered & sustainable system STRENGTHENING CLDS Equitable & personalized funding within limited resources 5

Project Tasks Phase 1 Phase 2 8 Tasks 7 Tasks 15 Tasks Total Phase 1 we’ll take a look at the current services for people with intellectual & other developmental disabilities and decide how they might be changed to make sure everybody’s needs are met. Phase 2 we’ll build a supports budget system with help from the Supports Intensity Scale (SIS) & a matching provider rate schedule. We’ll focus on those living at home with families first. STRENGTHENING CLDS 6

Data Presentation Data presentation and analysis ◦ General approach ◦ Supports needs assessment ◦ Level assignment ◦ Support needs by level by residence and spending ◦ Focus on people living home with family STRENGTHENING CLDS 7

General Approach An assessment assists with establishing supports budgets. The supports budget framework provides policy makers with information necessary to make fiscal choices that are fair & predictable, make the best use of available money, and are consistent with driving system principles. Allocating resources to people based on their assessed level of need means that each person receives what they need, no more no less. The supports budget framework established a best fit solution for most but takes care to accommodate individuals with extraordinary needs. STRENGTHENING CLDS 8

Looking Things Over Person Centered Planning Level Assignment Supports Budget SIS Results Assessed need SIS Interview Verification Results (SQs) Residence Supports Budget Control Sharing Results Level Assigned Policy Intentions Choice about Services Assess Needs Understanding the Process Service Delivery Base & Addon Services Policies TBD Supporting Policies, Rules & Regulations, and Communication STRENGTHENING CLDS 9

Personal Supports Budgets SIS Assessment Supplemental Questions Level Assignment Personal Supports Budget Verification STRENGTHENING CLDS 10

Assess Needs: Supports Intensity Scale Administration: Interview the person and others who know the person. Requires solid interviewing skills Measures general support needs of an individual producing a number of scores Includes basic support need areas like: A. Home Living Activities, B. Community Living Activities, C. Lifelong Learning Activities D. Employment Activities E. Health and Safety Activities F. Social Activities SIS ABE – refers to the sum of the scores for these 3 areas that have been found useful in helping resource allocation Identifies Medical and Behavior problems which are also significant cost predictors STRENGTHENING CLDS 11

Supplemental Questions and Verification During the SIS assessment, additional questions, called Supplemental Questions, are asked. These pertain to medical and behavioral support needs. Particular responses may indicate that further review of support needs is warranted. If so, additional questions are asked regarding: §Severe medical risk; §Severe community safety risk for people with a related legal conviction; §Severe community safety risk for people with no related legal conviction; §Severe risk of harm to self. Answers to these questions may trigger a review of individual records review called verification. Verification is a process where CLd. S staff review individual records to get a better idea of the individual’s particular needs. STRENGTHENING CLDS 12

SIS Assessment Status (11/18/15) Population Percent of Population Total SIS Assessments % Complete Agency Care 1, 453 25% 633 44% Foster Home 826 14% 305 37% Independent 1, 042 18% 311 30% Family 2, 080 36% 421 20% Other 407 7% 110 27% Total 5, 808 100% 1, 780 31% Living Setting STRENGTHENING CLDS 13

SIS Assessment by Region (11/18/15) Target Number Total Assessments* % Complete Central 255 100% Eastman 170 149 88% Interlake 173 171 99% Northern 66 60 91% Parkland 73 73 100% Westman 268 100% Winnipeg 1038 804 78% Total 2, 043 1, 780 87% Region * An additional 158 SIS assessments have been completed, but were excluded from further analysis because the individuals did not have full-year financial data STRENGTHENING CLDS 14

Number of People by Supports Need Score (low to high) (11/18/15) The scale shown is the sum of 3 SIS sub-scales regarding Home Living (A), Community Living (B) and Health & Safety (E). The combined scale (Sum A-B-E) can range from 852, low to high. Findings People: 1, 780 Mean: 24. 73 Median: Range: 25 8 - 48 STRENGTHENING CLDS 15

Comparison of Results in Manitoba with Other Jurisdictions Number of Individuals Supports Need Index Sum of Part A, B, and E Medical Need Score Behavioral Need Score SIS Norm 1, 306 100. 00 3. 23 4. 99 Manitoba 1, 780 93. 17 24. 73 1. 33 3. 20 Alberta 5, 061 91. 77 24. 81 1. 86 3. 73 Tennessee * 5, 765 102. 67 30. 36 1. 45 2. 87 Virginia ** 1, 275 102. 82 30. 16 1. 96 2. 64 Oregon * 5, 119 106. 33 31. 62 1. 99 5. 06 New Mexico * 3, 218 106. 31 31. 75 3. 13 4. 82 Utah 4, 114 102. 15 30. 09 2. 22 4. 09 Rhode Island 3, 007 101. 75 29. 72 2. 02 4. 19 Kentucky * 3, 476 99. 76 28. 93 1. 92 4. 28 99. 40 28. 62 1. 39 2. 69 Georgia 10, 574 Maine * 2, 324 98. 71 28. 35 2. 04 4. 64 Louisiana * 4, 091 98. 23 29. 95 3. 33 3. 10 Colorado 6, 849 97. 49 27. 91 2. 99 5. 55 * States with partial population for HCBS population **Weighted for entire HCBS population. STRENGTHENING CLDS 16

Level Assignment: Seven Levels must account for a range of support needs, but also categorical needs. Policy makers may adjust the services array, with different expectations about service use. STRENGTHENING CLDS 17

Seven Support Level Descriptions 1 Adults in this level have low support need, including some to no support need for medical and behavioral challenges. They can manage many aspects of their lives independently or with little assistance. 2 Individuals in this level need more support than those in Level 1, but their support needs are minimal to modest in a number of life areas. Adults in this level have moderate support needs and little to no support need for medical and behavioral challenges. 3 4 5 Adults in this level have low to moderate support needs as in Levels 1 and 2. They also have an increased, though not extraordinary, support need due to behavioral challenges. Adults in this level have moderate to high support needs. They need help with life activities on a daily basis. They may have behavioral support needs, but these needs are not extraordinary. Adults in this level have high to maximum support needs. They need help with life activities typically requiring hands on support and/or oversight throughout the day. They may have behavioral support needs, but these needs are not extraordinary. 6 Adults in this level have extraordinary need for medical support Individuals in this level may have behavioral needs, but these needs are not extraordinary. 7 All adults in this level have extraordinary behavioral challenges, regardless of their support need to complete daily activities or for medical conditions. Adults in this level need greatly enhanced supports due to their behavioral challenges. STRENGTHENING CLDS 18

Sum: Sections A, B, & E Section 3 A Med Support Section 3 B Behavior Support Least Support Needs 0 to 22 0 to 6 Mild or Moderate Support Needs 23 or 30 0 to 6 Mild to Moderate Support Needs & Moderate Behavioral Challenges 0 to 30 0 to 6 7 to 10 31 to 36 0 to 10 37 to 52 0 to 6 0 to 10 Support Levels 1 2 3 4 5 6 7 Moderate Support Needs & Mild to Moderate Behavioral Challenges High Support Needs & Mild to Above Average Behavioral Challenges 7 to 32 Extraordinary Medical Challenges Any or Verified Extraordinary medical risk 0 to 10 11 to 26 Extraordinary Behavioral Challenges Any STRENGTHENING CLDS Any or Verified Danger to others or Extreme self-injury risk 19

1, 780 People by Support Level & Living Option Level Distribution by Living Setting Total SIS Interviews Level 1 Level 2 Level 3 Level 4 Level 5 Level 6 Level 7 1, 780 620 (35%) 457 (26%) 149 (8%) 235 (13%) 29 (2%) 115 (6%) 175 (10%) Agency Care 633 103 (15%) 168 (27%) 66 (10%) 137 (22%) 10 (2%) 55 (9%) 92 (15%) Foster Home 305 94 (31%) 30 (10%) 37 (12%) 3 (1%) 15 (5%) 32 (10%) Independent 311 230 (74%) 43 (14%) 17 (5%) 7 (2%) 0 (0%) 5 (1%) 18 (6%) Family 421 161 (38%) 121 (29%) 24 (6%) 50 (12%) 16 (4%) 27 (6%) 22 (5%) Other/N. S. 110 39 (35%) 31 (28%) 12 (11%) 4 (4%) 0 (0%) 13 (12%) 11 (10%) Living Setting Overall STRENGTHENING CLDS 20

Level Distribution by Living Setting (n= 1, 780) Overall Agency Care N = 633 Foster Care N = 305 Independent Living N = 311 Parent/Extended Family N = 421 STRENGTHENING CLDS 21

FY 2015 Spending by Sum A-B-E score (Support Needs Score) STRENGTHENING CLDS 22

g! n i om ts C plo x o B s t’ a h W lot? p x a bo Explaining Boxplots STRENGTHENING CLDS 23

Fiscal Year 2015 Expenditures 633 People in Agency Care by Level STRENGTHENING CLDS 25 th % Median 75 th % Min Max Level 1 $54, 049 $69, 660 $82, 655 $1, 632 $286, 335 Level 2 $62, 638 $75, 938 $95, 923 $1, 280 $222, 716 Level 3 $70, 576 $99, 818 $148, 130 $31, 715 $420, 058 Level 4 $64, 242 $82, 873 $109, 659 $20, 414 $204, 845 Level 5 $63, 460 $82, 822 $114, 610 $37, 058 $141, 251 Level 6 $79, 774 $113, 986 $133, 940 $39, 595 $195, 158 Level 7 $79, 012 $123, 035 $194, 984 $1, 280 $319, 506 Overall $63, 349 $82, 873 $121, 746 $1, 632 $420, 058 24

Fiscal Year 2015 Expenditures 305 People in Foster Care by Level 25 th % Median 75 th % Min Max Level 1 $13, 038 $28, 375 $45, 169 $7, 118 $68, 608 Level 2 $15, 042 $23, 953 $40, 774 $4, 539 $74, 464 Level 3 $25, 346 $36, 807 $57, 548 $14, 299 $144, 546 Level 4 $21, 626 $28, 916 $42, 993 $2, 278 $94, 400 Level 5 $15, 773 $82, 822 $40, 018 $3, 650 $52, 140 Level 6 $35, 861 $40, 097 $53, 251 $23, 229 $78, 413 Level 7 $10, 280 $55, 845 $63, 758 $10, 280 $203, 203 Overall $17, 866 $30, 229 $50, 533 2, 278 $203, 203 STRENGTHENING CLDS 25

Fiscal Year 2015 Expenditures 311 People in Independent Living by Level 25 th % Median 75 th % Min Max Level 1 $4, 792 $8, 730 $17, 043 $1, 336 $50, 671 Level 2 $7, 119 $11, 013 $14, 802 $3, 456 $37, 843 Level 3 $5, 385 $25, 739 $37, 125 $1, 884 $59, 342 Level 4 $31, 133 $38, 998 $63, 731 $8, 824 $136, 645 Level 5 - - - Level 6 $9, 349 $14, 684 $20, 379 $3, 833 $25, 894 Level 7 $8, 980 $24, 355 $33, 225 $2, 675 $70, 679 Overall $5, 225 $9, 734 $19, 968 $1, 336 $136, 645 STRENGTHENING CLDS 26

Focus on Individuals Living Home with Families People adults living home with families have more complicated spending patterns. • They may access a variety of CLd. S services, such as inhome “enhanced support”, several forms of respite, day services, transportation, crisis support, specialized therapies, and other expenses. • Service use patterns (and so spending) vary by individual. • Service use may not be consistent month to month, and may involve several months in the year with no spending STRENGTHENING CLDS 27

Fiscal Year 2015 Expenditures People Living with Families 25 th % Median 75 th % Min Max Level 1 $3, 414 $8, 174 $17, 549 $160 $53, 521 Level 2 $7, 151 $16, 429 $36, 321 $107 $48, 838 Level 3 $7, 081 $22, 131 $36, 401 $240 $65, 025 Level 4 $11, 098 $30, 914 $66, 078 $435 $66, 078 Level 5 $17, 448 $38, 529 $49, 352 $5, 034 $68, 505 Level 6 $19, 532 $35, 579 $50, 879 $1, 284 $103, 671 Level 7 $12, 653 $38, 035 $57, 550 $1, 679 $102, 297 Overall $6. 719 $15, 704 $32, 005 $107 $103, 671 STRENGTHENING CLDS 28

Illustration of the Number of People Living Home with Families Who Use Each Service (FY 2015) STRENGTHENING CLDS 29

Illustration of the Number of People Living Home with Families Who Use Each Primary Service Type (FY 2015) STRENGTHENING CLDS 30

Service Use and Costs of 421 Individuals Living at Home with Families by Primary Service Type (FY 2015) Number Using Service Percent of 421 Using Service Total Cost Average Cost per Individual User Clinical services 27 5. 7% $30, 246 $1, 120 Crisis services 3 0. 70% $7, 364 $2, 455 Day services 308 73. 2% $5, 837, 665 $18, 953 Residential services 66 15. 7% $713, 498 $10, 810 Respite 188 44. 7% $1, 014, 348 $5, 395 Transportation 181 43. 0% $681, 670 $3, 766 Service Type STRENGTHENING CLDS 31

Service Use of Individuals Living at Home with Families (FY 2015) STRENGTHENING CLDS 32

Service Use of Individuals Living at Home with Families by Primary Service Type (FY 2015) Residential Services (n = 66) 25 th % Median 75 th % Min Max Level 1 $1, 797 $7, 626 $13, 020 $84 $31, 747 Level 2 $985 $2, 857 $12, 467 $248 $46, 256 Level 3 $11, 934 $11, 987 $14, 504 $329 $23, 123 Level 4 $2, 192 $3, 700 $6, 178 $1, 408 $14, 433 Level 5 - $21, 411 - - - Level 6 $5. 363 $10, 785 $31, 017 $294 $49, 070 Level 7 $5, 271 $12, 829 $31, 401 $1, 346 $47, 266 Overall $1, 738 $6, 890 $14, 265 $84 $49, 070 STRENGTHENING CLDS 33

Service Use of Individuals Living at Home with Families by Primary Service Type (FY 2015) Respite Services (n = 188) 25 th % Median 75 th % Min Max Level 1 $839 $1, 890 $4, 097 $10 $12, 548 Level 2 $1, 590 $3, 192 $5, 106 $152 $19, 353 Level 3 $1, 554 $3, 560 $4, 563 $280 $20, 574 Level 4 $1, 593 $6, 746 $9, 171 $294 $20, 860 Level 5 $5, 016 $5, 280 $14, 987 $94 $16, 513 Level 6 $1, 675 $3, 201 $6, 949 $972 $26, 310 Level 7 $2, 944 $5, 712 $13, 770 $1, 679 $43, 803 Overall $1, 568 $3, 306 $6, 823 $10 $43, 808 STRENGTHENING CLDS 34

Day Service Use by Living Setting Total SIS Interviews Any Day Services Regular Special Rate Other 1, 780 1, 190 (66. 9%) 1, 134 (63. 7%) 765 (67. 5%) 71 (4. 0%) Agency Care 633 468 (74. 0%) 464 (73. 3%) 329 (71. 0%) 4 (<1%) Agency Care 24 hour 172 Foster Home 305 234 (76. 7%) 228 (74. 8%) 159 (52. 1%) 7 (2. 3%) Foster Home 24 hour 36 Independent 311 147 (47. 3%) 125 (40. 2%) 46 (36. 8%) 32 (10. 3%) Family 421 308 (73. 2%) 289 (68. 6%) 208 (71. 9%) 35 (8. 3%) Other/N. S. 110 33 (30. 0%) 28 (25. 5%) 23 (82. 1%) 3 (2. 7%) Living Setting Overall STRENGTHENING CLDS 35

Day Service Use by Living Setting Level Total SIS Interviews Any Day Services Regular Special Rate Other Overall 1, 780 1, 190 (66. 9%) 1, 134 (63. 7%) 765 (67. 5%) 71 (4. 0%) 1 610 388 (63. 6%) 348 (87. 0%) 165 (47. 4%) 58 (9. 52%) 2 457 329 (72. 0%) 321(70. 2%) 195 (60. 7%) 8 (1. 8%) 3 149 100 (67. 1%) 98 (65. 8%) 76 (77. 6%) 0 (0. 0%) 4 238 179 (75. 2%) 177 (74. 4%) 153 (86. 4%) 1 (<1%) 5 29 21 (72. 4%) 21 (100%) 0 (0%) 6 112 75 (67. 0%) 74 (98. 7%) 68 (91. 9%) 3 (2. 7%) 7 175 100 (57. 1%) 97 (55. 4%) 87 (89. 7%) 1 (<1%) STRENGTHENING CLDS 36

Next Steps Sales & Savage STRENGTHENING CLDS 37

CLd. S Intends to • Increase resources to connect people to their communities • Increase competitive employment for participants • Sharpen and adjust the service array • Align our effort person with assessed support needs • Assist service providers to refine and/or grow their array of services • To ensure a fair system with the implementation of a standardized assessment model • Provide a long-term sustainable system of supports STRENGTHENING CLDS 38

There is still more to do • Departmental implementation team has been largely set. • Work is proceeding with HSRI to consider findings related to support needs assessments, spending analyses and other related issues. • CLDS has engaged with Helen Sanderson Associates (HSA) Canada regarding providing staff with Person Centered Thinking training. • A phased in approach to making and system changes was chosen. • A pilot will begin on January 1 starting with new admissions to the CLDS system. • Rollout elsewhere will take time, and will be discovered through continued achievement and discussion. STRENGTHENING CLDS 39

Focus on Individuals Living Home with Families: What’s Next? • In-depth understanding of money spent per service type (respite, supports to family, day services, transportation, clinical services, and crisis services). • Discussions between CLd. S and stakeholders about the type and amount of supports that will be made available to individuals living home with families at each support level. • Policy decisions by CLd. S about investment in services for individuals living home with families. • Settle on anticipated service use and supports budgets for individuals living home with families. • Assure needed infrastructure for supports planning and exceptions review. • Enrollment of first group of individuals living home with families—SIS assessments are currently underway. STRENGTHENING CLDS 40

Person-Centered Planning • Individuals define their goals and aspirations. • SIS assessment results can be used to understand areas of strength and areas where the individual needs support. • Individuals (and their families, when applicable) are made aware of their supports budget before the planning meeting takes place. • Individuals have some degree of authority and flexibility to choose which services to purchase. • Individuals work with their circle of support to decide on the other types of support that they require to achieve their goals (relationships, community based, etc. ) • All paid and non-paid supports work in harmony to help the person achieve their defined goals. STRENGTHENING CLDS 41

Discussion and Questions STRENGTHENING CLDS 42

Dancing with Dragons “The final act in performing a creative act is letting go. … As we create new support practice, the proverbial beast is provoked. We are knocked off our centers as we move into unknown territory without the anchor of our legacy services. This requires… as Rebecca Chan says, [that we] Dance with our Dragons. ” Hanns Meissner, Blue Space, p. 146 43 STRENGTHENING CLDS