The Ohio Department of Development Disabilities (DODD) recently released updated data highlighting progress on several key initiatives, including expanding home-and-community based service (HCBS) waiver enrollment and increasing access to community employment. These initiatives were developed as a result of the last biennial budget, which included a $300 million investment in DODD services, mostly aimed at increasing access to community living for individuals with developmental disabilities. Overall, the new data scorecard suggests that progress has been slow over the first three quarters of the year, and much headway will be necessary to achieve the goals outlined during the budget process.
HCBS Waivers
The 2016-2017 biennial budget (House Bill 64) included the addition of 3,000 state-funded HCBS waivers, intended to make a dent in the state’s lengthy waiver waiting list (over 40,000 people), and to assist those currently living in intermediate care facilities (ICFs) who want to leave. HCBS waivers allow eligible individuals to receive the care they need in the community, as opposed to an institutional setting. According to the most recent score card, only about 6 percent of the 1,864 waiver slots targeting the waiting list have been filled. Just five individuals have enrolled in the 1,136 state-funded “exit and diversion” waivers, intended for those currently living in an institution or those being diverted from an institution, who want to live in the community. However, according to the Department, an additional 148 waivers have been approved for allocation for exit and diversion, but formal enrollment is not yet complete. Including these approved-but-not-enrolled waivers, just 13 percent of the total exit and diversion waivers have been utilized to date. There are currently an estimated 2,500 individuals living in institutions who want to leave; of these, only three have been enrolled in these new waivers so far.
Ohio is one-third of the way through the budget cycle, but total enrollment in these new waivers has reached just 4 percent.
Conversion of ICF beds (to waivers) and downsizing of large ICF facilities represents another component of the administration’s plan to rely less heavily on institutions for care. The recent report shows that 58 beds have been downsized and 44 have been converted since the start of the fiscal year.
Relatedly, DODD just announced that it is requiring that 25 percent of the new state-funded Individual Option (IO) waivers (864 in total) go to those individuals who choose “shared living” services. Ohio has been seeking to increase the number of individuals with developmental disabilities who utilize this service model, which is more widely used in some other states. Shared living occurs when a community member operates as a home provider, and houses and takes responsibility for the care of an individual with a developmental disability. If a county can’t fill their shared living slots, they will be redistributed to other counties. This fiscal year, 13 individuals now enrolled in state-funded IO waivers have chosen shared living options, though the new requirement may result in growth in this area. Overall, almost 7 percent of IO waiver recipients receive shared living services.
Community Employment
The budget allocated $3 million per year to promote integrated community employment for individuals with developmental disabilities. This allocation came as the state continues to face pressure (from both the federal government and outside advocacy groups) to adjust the current model for delivering day and employment services, which currently relies heavily on sheltered workshops, and to more actively support community employment for individuals with developmental disabilities. The scorecard data on employment suggests a slow start to moving the needle. Despite efforts to the contrary, participation in facility-based work supports, or sheltered workshops, has increased over the past three quarters across the state, and still represents over 50 percent of total participation. Integrated community employment has seen a slight increase, starting the year with 8,375 participants, and ending the third-quarter at 8,634. This continues to represent about 25 percent of total employment/day support participation.
County-by-county employment data shows that some counties have integrated employment participation of over 50 percent, while others have rates of less than five percent. This disparity is particularly striking as DODD recently announced that the federal government will likely not grant the state 10 years to integrate waiver service settings as requested, including sheltered workshops; the state will need to abide by a 5 year timeline, ending in 2019. These data suggest that many counties continue to rely heavily on sheltered workshops and segregated adult day programs, and could face a harsh transition as they seek to come into compliance.
Conflict of Interest
In 2014, the federal government reminded states that there must be a separation between the entity that provides the case management function to individuals with disabilities, and entities responsible for the provision of waiver services. A lack of separation, the federal government believes, represents an inherent conflict of interest, and is not allowable. This requirement has proven challenging for Ohio, where many local boards of developmental disabilities also directly provide these waiver services. In short, private providers will be necessary to fill in the gaps for services that boards are no longer able to provide directly.
The data scorecard from DODD provides some insight into local board efforts to transition away from direct-service provision, to comply with this rule. Overall, the data show that 45 percent of waiver services are provided by county boards (the remainder are delivered by private providers). In several counties, 75 percent or more of waiver services are delivered by the board, indicating that many areas still face a significant change in their service delivery model as this transition continues.
Despite these delays, the scorecard does outline some successes for the Department. This includes the successful implementation of a 6 percent rate increase for direct service workers, as well as approved reimbursement increases for ICFS, and increased attention to ensure people are fully aware of their options when seeking services.
The 2016-2017 budget was ambitious in its initiatives to support the developmental disabilities system, and to create more opportunities for community living. However, much of this promised change has yet to realized, as progress on these initiatives is off to a slow start. There is much work to be done, both locally and by the state, to address the necessary changes facing the system. We remain hopeful that data from upcoming quarters will indicate improvement in these areas as the state seeks to reshape the current system.