 “[W]e confront the question whether the proscription of discrimination may require placement of persons with mental disabilities in community settings rather than in institutions.”  “The answer … is a qualified yes.”

 “A public entity shall administer services, programs and activities in the most integrated setting appropriate to the needs of qualified individuals with disabilities.”

 “A public entity shall make reasonable accommodations in policies, practices and procedures …  unless … making the modifications would fundamentally alter the service, program or activity.”

 Two women, Lois Curtis and Elaine Wilson, who were institutionalized at Georgia Regional Hospital …  sued Tommy Olmstead, the Commissioner of the Georgia Department of Human Resources

 Ruled for Ms. Wilson & Ms. Curtis  Found that Georgia “could provide services to [Ms. Wilson & Ms. Curtis] in the community at considerably less cost than is required to institutionalize them.”

 Sent the case back to the trial judge on cost of community care  Asked “whether the additional expenditures … would be unreasonable given the demands of the State’s mental health budget.”

 “First, institutional placement of persons who can handle or benefit from community settings … perpetuates unwarranted assumptions … that persons so isolated are incapable or unworthy of participating in community life.”

 “Second, confinement in an institution severely diminishes the everyday life activities of individuals, including:  Family relations,  Social contacts,  Work options,  Economic independence,  Educational advancement, and  Cultural enrichment.”

 When “the State’s treatment professionals have determined that community placement is appropriate,  the transfer from the institution to a less restrictive setting is not opposed by the affected individual,

 and the placement can be reasonably accommodated, taking into account ◦ the resources available to the State ◦ and the needs of others with disabilities.”

 When the State, “generally rely[ing] on the reasonable assessments of its own professionals,” determines that habilitation needs can only be met in an institution.

 When “in the allocation of available resources, immediate relief … would be inequitable, given the responsibility the state has undertaken for the care and treatment of a large and diverse population of persons with disabilities.

“If the State were to demonstrate that it had  a comprehensive, effectively working plan for placing qualified individuals with disabilities in less restrictive settings,  and a waiting list that moved at a reasonable pace, not controlled by the State’s endeavors to keep its institutions fully populated, the reasonable-modifications standard would be met.”

 “[T]he range of facilities the State maintains for the care and treatment of persons with diverse mental disabilities,  and its obligation to administer services with an even hand.”

 “Nor is it the ADA’s mission to drive State’s to move institutionalized patients into an inappropriate setting, such as a homeless shelter.”

 “We emphasize that nothing in the ADA or its implementing regulations condones termination of institutional settings for persons unable to handle or benefit from community settings.”

 “Nor is there any federal requirement that community-based treatment be imposed on patients who do not desire it.”

Source: Centers for Medicare and Medicaid Services

Total Nursing Home Population in the United States: ~1.35 Million SOURCE: CMS Minimum Data Set 2.0 (1 st Q 2010)

 Medicaid:54% (729,000)  Medicare:25% (337,500)  VA:1% (13,500)  Self/family:13%(175,500)  Private insurance:9%(121,500) SOURCE: CMS MDS 2.0

Total: $61 BillionTotal: $45 Billion Institutional Spending:  Nursing Homes: $49 Billion  ICF/MR (for persons with developmental disabilities): $12 Billion Community Spending:  Home and Community services (waivers, all disabilities): $30 Billion  Personal Care option: $11 Billion  Home Health: $4 Billion

 Under 30:.5% (6,750)  31 to 64:14%(189,000)  65 to 74:14%(189,000)  75 to 84:28%(378,000)  Over 85:50%(675,000)

 An acute care hospital:61%  Another nursing home:13%  A private home with no home health services:10% SOURCE: CMS MDS 2.0 (1 st Q 2010)

 United States:23%(310,500)  California:27%(26,460)  Illinois:25%(18,250)  Louisiana:16%(4,000)  Michigan:30%(11,700)  New York:21%(22,260)  Oregon:35%(2,555)  Texas:20%(18,600)  Utah:37%(1,872) SOURCE: CMS MDS 2.0 (1 st Q 2010)