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Community Living Initiative (CLI) - Key Advances During the Year of Community Living

In response to President Obama’s June 2009 call for a Year of Community Living initiative, Health and Human Services Secretary Kathleen Sebelius has led the charge for major reform.  Through an alliance across the Department and with other Federal Departments, many key advances in improving the lives of people with disabilities and ensuring their right to live meaningful lives in the community have been accomplished.  With the support of new authorities under the Affordable Care Act (ACA), the Community Living Initiative has a clear charge to lead the way to enhanced opportunities for people with disabilities to live with respect and dignity as full members of their communities.

Opening the doors to our partners –

Stakeholder Dialogues - HHS hosted dialogues with key stakeholders across the country including state and local officials and members of the community.  Attendees offered critical input that is informing public policy and practice to better meet the needs of people with disabilities and older Americans, particularly those with chronic conditions.  In 2010, the following dialogues took place across the United States: San Diego, CA (February 18); Raleigh, NC (April 6); Fairfax County, VA (April 19), and Boston, MA (May 27).

Opportunities for Public Input - The Advanced Notice of Proposed Rulemaking (ANPRM) published as a part of the Year of Community Living in June 2009, enabled the public to comment on specific potential changes to the 1915(c) Home and Community-based Services (HCBS) waiver program, including combining of target groups within HCBS waivers and to identifying key characteristics of settings where HCBS can be provided.  The ANPRM also sought public comment on person-centered planning and how we can ensure that services are provided to individuals in ways that meet their needs and preferences.  After a careful review of more than 300 comments, CMS plans to publish a Notice of Proposed Rulemaking (NPRM) to address the issues raised by the public and to solicit additional input from stakeholders. 

Advancing partnership with states -

On May 20, 2010, the Centers for Medicare and Medicaid Services (CMS) released a “Community Living Initiative letter” to State Medicaid Directors.  While reaffirming their commitment to the policies identified in previous “Olmstead Letters”, CMS offered tools and information to help States make greater strides in achieving the promise of the Americans with Disabilities Act (ADA) and Olmstead.  CMS reminded states of the availability of technical assistance,  management of long-term  services and supports; advancing access to affordable housing as a means to maximize opportunities for community living; home and community based services (waiver and State plan options); support for infrastructure reforms; HCBS participant experience measures; aging and disability resources centers (ADRCs); and discharge planning.

Increasing Access to Affordable Housing -

The CLI is fostering new and emerging partnerships between HHS and Housing and Urban Development (HUD) to provide people with disabilities with affordable and accessible housing along with critical long-term services and supports. 

Housing Vouchers - HHS is partnering with HUD to leverage the $40 million in Housing Choice vouchers for 5,300 people over 12 months (announced by HUD on April 5, 2010) for non-elderly people with disabilities living in the community or transitioning out of institutional care.  HHS is using its network of State Medicaid agencies and local human service organizations to link eligible individuals and their families to local housing agencies.   CMS anticipates that participants transitioning from institutions to the community under its MFP Demonstration and Medicaid recipients of home and community-based services already residing in the community will benefit from these vouchers. CMS is supporting technical assistance to its MFP grantees, State Medicaid Programs, and State Public Housing Authorities to facilitate the necessary relationships among these agencies so they can complete a competitive application for these vouchers.

Capacity Building Contract - In an effort to ensure the successful creation and sustainability of a collaborative relationship between housing and human service agencies in MFP Demonstration states, CMS is currently reviewing proposals to launch a Housing Capacity Building Initiative for Community Living that will support these two groups to learn the intricacies of each other’s operations and work with one another in a mutually supportive fashion.  This effort will provide technical assistance (e.g., helping stakeholders navigate Federal statutory and regulatory requirements; assisting non-profit organizations in developing better community-based supports) to State and local entities to plan and implement effective program options that link housing with long-term care services and supports for people with disabilities and older adults. It will also focus on bridging gaps between services and creating accessible, affordable housing options for people with disabilities and long-term care needs. 

Housing Resource Coordinators (HRC) - Once collaborative relationships have been initiated between state and local human service and housing agencies, CMS will fund its MFP grantees to establish HRCs to sustain these relationships. HRCs will work with human service agencies to identify the accessible & affordable housing needs of persons with disabilities and chronic conditions within a state, and then facilitate the use of this information to inform the future development and distribution of housing resources under PHAs & HFAs. To accomplish these goals, the HRC will maintain working relationships with both human service and housing agencies at the state and local levels, and foster and sustain direct collaboration between the human service and housing agencies as well.

Empowering people to make informed choices –

Aging and Disability Resource Centers (ADRC) -  AoA and CMS jointly awarded $60 million in formula and competitive grants authorized under the Affordable Care Act (ACA).  This grant program -- entitled  "Implementing the Affordable Care Act to Make it Easier for Individuals to Navigate their Health and Long-Term Care through Person-Centered Systems of Information, Counseling and Access”— is a most welcome expansion of  Resource Centers that serve as “visible and trusted” sources where people can turn for objective information on their long-term services and support options and their Medicare benefits.  ADRCs also provide “one-on-one” counseling and advice to help consumers, including private pay individuals, to fully understand how available options relate to their particular needs as well as a streamlined eligibility process for those who qualify for publicly funded long-term services and support programs.      

The grants include:

  1. Formula funds will be available to States, Area Agencies on Aging (AAAs), State Health Insurance Assistance Programs (SHIPs) and Aging and Disability Resource Centers (ADRCs) to provide outreach and assistance to Medicare beneficiaries on their Medicare benefits including prevention.
  2. Two competitive funding opportunities available to all existing ADRC grantees:
    1. Strengthening of  ADRCs’ Options Counseling and Assistance Programs,
    2. Strengthening the role of ADRCs in Evidence-Based Care Transition Models that integrate the medical and social service systems to help older individuals and those with disabilities remain in their own homes and communities after a hospital, rehabilitation or skilled nursing facility visit.
  3. Existing MFP state grantees will be able to compete for supplemental administrative funds that can be used to strengthen the capacity of existing ADRCs to participate in Nursing Home Transitions and Diversions Programs.     

The Center for Technology and Aging, with support from the SCAN Foundation, will be making additional funds available to states that are awarded grants under this Announcement for ADRC Evidence-Based Care Transition Programs to support the use of assistive technology in those programs.

Making the “money follow the person” to the community –

CMS is working to fulfill an important promise of the ACA that will truly make “money follow the person” to the community.  By extending the demonstration grant program an additional five years to 2016 and taking advantage of an additional appropriation of $2.250 billion, CMS was able to award MFP Demonstration grants to 13 additional states in February 2011 for a total of $621 million through 2016. This brings the total number of MFP grantees participating in the demonstration to 43.  The law also allows states to transition people out of institutions more quickly by reducing the eligibility requirement for a participant to be in an institution from 6 months to 90 days.

The Community Living Initiative has supported collaboration with HUD in this area as well.  Many Money Follows the Person (MFP) grantees have created or enhanced housing registries (e.g., interactive and online). In addition, HUD and HHS collaborated to offer funding opportunities to support persons at risk of institutionalization to remain in the community and to those interested to returning to the community from institutional settings. This initiative resulted in the award of 5,300 housing vouchers targeted to non-elderly disabled individuals.

After four years in place, the original 30 MFP grantees (twenty-nine States and the District of Columbia) have transitioned 12,000 individuals from institutional settings into community settings with necessary supports and services. The program reimburses States at an enhanced Federal match for services for each participant enrolled for 365 days after transition.

Building the Infrastructure for Research on Disability Services

The Office on Disability awarded Mathematica Policy Research Inc. a $6.3 million contract to establish a Center of Excellence in Research on Disability Services, Care Coordination, and Integration. This two-year project, funded under the American Recovery and Reinvestment Act of 2009, will create the data infrastructure to support the development of comparative effectiveness research on services and supports and models of care for persons with disabilities. This initiative may bring relevant findings that can be used to support community living.

Ensuring the rights of people with disabilities -

HHS Civil Rights Enforcement -

The HHS Office for Civil Rights (OCR) remains committed to ensuring compliance with the ADA and the Supreme Court’s Olmstead decision.  From April 2000- April 2010, OCR investigated over 500 Olmstead complaints and achieved corrective action in approximately 60% of the complaints.  In addition to resolving individual complaints, OCR also investigated systemic, statewide violations of the ADA and the Olmstead decision.  For example, in response to several ADA complaints from advocates, OCR investigated and entered into a voluntary compliance agreement with the State of Georgia on July 1, 2008. The agreement required the state to transition individuals with developmental disabilities and mental illnesses from the state institutions to the community.  After numerous meetings and letters expressing concerns with the state’s failure to implement the agreement, on January 26, 2010, OCR issued a detailed letter to the Governor finding the state in non-compliance with the agreement.  Shortly thereafter, the Department of Justice (DOJ) filed a complaint in federal court against the state alleging violations of the ADA with respect to individuals in the state facilities.  DOJ and OCR are working together to ensure that the state complies with the ADA.

Though the Community Living Initiative, OCR has collaborated with DOJ to ensure vigorous enforcement of the ADA.  DOJ is actively intervening in federal court cases and filing amicus briefs in district and appellate courts.  DOJ is also bringing ADA complaints seeking systemic reform of state systems serving individuals with mental health needs and developmental disabilities.  OCR is working with DOJ to ensure consistent interpretations of law in resolving complaints and seeking ADA compliance.  OCR also is coordinating with the HHS Office of the General Counsel and CMS to provide DOJ with information on relevant HHS programs and requirements.

Effective discharge planning – Paving the way to the community

Minimum Data Set (MDS) for Certified Nursing Facilities -  On October 1, 2010, all certified nursing facilities will be required to adopt and implement a new 3.0 version of the MDS -- a standardized, primary screening and assessment tool of health status which forms the foundation of the comprehensive assessment for all residents of long-term care facilities certified to participate in Medicare or Medicaid.  While MDS 3.0 has several new enhancements to ensure resident assessments are more person-centered, there are notable changes in the MDS’ Section Q, which address resident discharge planning.  Under Section Q, nursing facilities must now ask residents directly if they are “interested in learning about the possibility of returning to the community.”  If a resident indicates yes, a facility will be required to make appropriate referrals to community integration agencies such as Aging and Disability Resource Centers (ADRCs), Centers for Independent Living, State Medicaid Agencies, and Area Agencies on Aging. 

Technical Assistance for Implementation of Preadmission Screening and Resident Review (PASRR) - CMS established the new National PASRR Technical Assistance Center, which provides technical assistance to States, at no cost, to ensure that individuals with mental disorders or developmental disabilities considered for admission to a nursing facility are evaluated to determine the most integrated setting to meet their needs.  CMS connected the dots between the MDS and the PASRR process by including a PASRR element in the MDS that will assure a person-centered process to help nursing facility residents to transition to community services.

Partnerships to advance employment of people with disabilities

Supported and Customized  Employment for People with Disabilities  - The Community Living Initiative is forging partnerships to promote the braiding of federal funds to enhance opportunities for people with disabilities to work.  CMS and the Office of the Assistant Secretary for Planning and Evaluation are collaborating with the Rehabilitation Services Administration, Social Security Administration, Department of Labor, and Substance Abuse and Mental Health Services Administration to produce a guide for the Federal financing of supported and customized employment by Fall, 2010.  This guide will undoubtedly serve as an important resource for states who are striving to promote valued economic roles for people with disabilities.