1. Preliminary Findings: Real Choice Pilot Presentation to the Consumer Planning and Implementation Group September 28, 2006

2. 2 Introduction Real Choice piloted a “Cash and Counseling” model in Massachusetts using a cross-disability approach 1 st year of pilot was grant funded; next three years will be sustained through State funds Lessons learned from Real Choice will be applied to the 1115 “Community First” waiver (through an Independence Plus option) UMMS/CHPR has conducted evaluation activities in addition to administration responsibilities (No funds were allocated in the grant for a separate evaluation)

3. 3 Real Choice Pilot Overview Goal: To increase participants’ quality of life and independence through the use of consumer-directed flexible funding Key Components: –Assessment –Surrogacy Option –Individual Budgeting –Support Brokerage –Spending Plans –Back Up Plans –Fiscal Intermediary Subcontracts Administering the Pilot: –Elder Services of Worcester Area (Support Brokerage) –Options, Cerebral Palsy of Mass. (Support Brokerage) –Stavros Independent Living Center (Fiscal Intermediary)

4. 4 Evaluation Goals Evaluate the extent to which the Pilot’s use of consumer-directed flexible funding increased participants’ quality of life & independence (Consumer Quality Initiatives, Inc.) Report on implementation experiences (UMMS/CHPR and Kenneth Schlosser) Provide “lessons learned” for future implementation of Independence Plus option

5. 5 Evaluation Feedback Process Reports Available for Review Now: –Outreach and Enrollment –Individual Budgeting –Spending Plans –Support Brokerage –Fiscal Intermediary –2-Month Participant Interviews –Case Studies –Focus Group Results Reports to be Released in October: Assessment, Cost Data, 9-Month Participant Interviews, as well as Support Brokerage Themes and Recommended Training Please Send All Questions, Feedback, and Comments to Emma Quach by 10/31/06 emma.quach@umassmed.edu oremma.quach@umassmed.edu 508-856-8112

6. 6 Evaluation Methods Participant interviews conducted by Consumer Quality Initiatives, Inc. at 2 and 9 months Focus groups conducted with community liaisons, paid caregivers, and unpaid caregivers Case studies written to tell individual participant stories Qualitative analysis of outreach and enrollment, assessments, budget methodology, spending plans, support brokerage, and fiscal intermediary processes Quantitative analysis of expenditures to understand participants’ costs prior to and during the Pilot

7. 7 Demographics of Pilot Participants (Total=14)

8. 8 Self-Reported Diagnosis of Participants (Total=14)

9. 9 Pilot Outreach and Enrollment Pilot Eligibility: Have MassHealth or meet eligibility for MassHealth Have two or more unmet needs related to ADLs or IADLs Not eligible for the Personal Care Attendance (PCA) program Pilot Targeted Groups: People with diverse disabilities Examples of population groups: elders, people with mental health disabilities, people with mental retardation, people with developmental disabilities, and people not eligible for the PCA program

10. 10 Outreach and Enrollment CHALLENGESSTRATEGIES Time intensive to conduct outreach and explain model Provide ample time for outreach and enrollment Provide written materials that describe both opportunities and responsibilities Applications were submitted by individuals other than consumers Assist applicants in completing applications Further explain model to individuals and those who support them Difficult to Ensure Cross-Disability and Age of Applicants Collaboration with other agencies to help increase applicant diversity Provide outreach materials in accessible formats and languages Increase general consumer & community training and education on consumer-direction, e.g., to avoid bias selection of applicants

11. 11 Role of the Support Brokerage Agency Outreach and enrollment Assessment and re-assessments Overall day-to-day administration of Pilot Training and supervision of community liaisons Participants Chose their Community Liaison, who Assisted the Individual to: Design, revise, and monitor their spending plan/budget, e.g., identify potential services and supports Implement spending plan, e.g., complete required worker forms Ensure an emergency back up plan is in place Provide training as necessary, e.g., recruitment and management of workers and proper compliance with reimbursement processes

12. 12 Support Brokerage Elder Services of Worcester Area (an Aging case management agency) Cerebral Palsy of Mass. (Supported Living and PCA provider agency) Southeast Center for Independent Living (SCIL) (Independent Living Center) Monthly Support for Consumers 2-4 hours/month4-14 hours/month Affiliations of Community Liaisons Case managers and providers employed by other entities - In-House Skills Trainers - Family/Friends of Consumers - In-house Skills Trainers - Family/Friends of Consumers

13. 13 Support Brokerage Strengths Elder Services of Worcester Area Established infrastructure and resources for administration Use of tools from consumer-direction pilot already in existence Cerebral Palsy of Massachusetts Strong foundation based on consumer-directed philosophy Experience with consumer-directed service delivery Southeast Center for Independent Living Strong foundation based on consumer-directed philosophy

14. 14 Support Brokerage Challenges and Lessons Learned Challenge: Insufficient Training Provided to Participants Provide upfront/ongoing training to support brokers/ agencies on consumer-direction and program guidelines and processes Allow time for time consuming tasks (such as spending plan design) Challenge: Inflexible Level of Support Provided by Community Liaisons Allow community liaison’s (or other supportive entity) to spend time required to meet the needs of the individual (esp. for those who would otherwise need representative) Establish clear roles and responsibilities for support brokers while being flexible enough to encourage participant learning and independence

15. 15 Role of the Fiscal Intermediary Cut checks and payments for workers and approved purchases Provide fiscal reporting and monitoring documents, such as timesheets and monthly spending reports in an accessible format and language Payment of funds on an emergency basis as needed Comply with federal and state tax requirements, e.g., payment of unemployment taxes and workers’ compensation

16. 16 Fiscal Intermediary Challenges and Lessons Learned Challenge: Payment Mechanisms for Non-worker Purchases Implement flexible purchasing/payment methods to minimize upfront payment by participants Examples include invoicing transportation companies and using the internet and gift registries Challenge: Lack of Proper Documentation for Payment Systematic and clear processes and forms for fiscal intermediary, consumer, and support broker All individuals (fiscal intermediary staff, consumer, and support broker), should be well-trained on these processes

17. 17 Fiscal Intermediary Challenges and Lessons Learned Challenge: Spending Plans- Too Detailed or Broad Attach possible purchases for each category and avoid writing spending plans that are too specific/broad Support brokerage agency to work with participants before submitting spending plans to fiscal intermediary Challenge: Monitoring Frequent Spending Plan Changes Provide fiscal intermediary with only modified pages of spending plan, with the date when pages were modified Limit changes to once a month Use of web-based or electronic forms and communications

18. 18 Individual Budgets All 14 budgets developed using combined developmental and standardized process Range of budgets: $8K - 36K (highest budgets for individuals in nursing home or at risk) Budgets allocated/utilized: $246K/117K (48%) as of end of June 2006 (14 budgets) Developmental budget process found to be meaningful method to develop budgets for individuals diverse in needs and disability Developmental budget process is time-consuming, and accuracy of this methodology is subject to consumer and community liaison’s ability to identify needs and services to meet those needs upfront

19. 19 Budget Allocation vs. Utilization as of June 30, 2006

20. 20 Spending Plans as of June 30, 2006 About 50 percent of budget expenditures were for directly hired workers (about $70K) Most workers provided assistance with homemaking, transportation, errands, and personal care. Workers were paid between $10-$15/hr More than half of participants hired family/friends for workers, and these participants had no worker turnover during first year Unusual requests: Attorney fees related to child custody, decorative household items (both denied), air transportation (approved)

21. 21 Spending Plan Purchases as of June 30, 2006 Home/Vehicle Modifications $13,849

22. 22 Purchases Similar to Traditional Medicaid Services Hospital Bed and Walker (Easier to purchase) Scooters (Individual not eligible under Medicaid) Dental Care (Not covered by MassHealth at the time) Dentures (Not covered by MassHealth at the time) Orthopedic Shoes (Easier to purchase) Eyeglasses (Not covered by MassHealth at the time) Personal Care Supplies related to IV use (Not all supplies were covered in desired quantity)

23. 23 Air conditioners for better air quality/comfort Computers for employment training, education, and management of self-direction responsibilities Fax machines for communication and management of self-direction responsibilities Shower chair/rails for independence with bathing Kitchen supplies for independence with meal preparation Washer and dryer for independence with laundry Closed circuit television for visual support Gym membership for healthy living Social activities for increased community integration Creative Purchases

24. 24 Total Service Costs for Participants (2003-2006)

25. 25 Thank You for Your Attention Questions or Comments?