Linking Housing to Supports: NC’s Olmstead Initiatives

1. Linking Housing to Supports: NC’s Olmstead Initiatives Ellen Blackman, Ken Edminster & Trish Farnham

2. Important Milestones in Long-Term Services and Supports Transition Activities

3. Game-Changing Milestones in Long-Term Services and Supports 1999 1980s 1990s 2000s 1965 and1970s

4. Medicare and Medicaid Begin • Pre 1980s: Long Term Services and Supports (ongoing support with activities of daily living) were largely provided in facilities or by family members. • Medicaid LTSS was limited to facility-based care. • Medicare still does not provide LTSS (short-term home health only). • Housing not coverable.

5. Medicaid Funds LTSS 1980s: Advocacy efforts push for increased parity of LTSS public dollars and the “Medicaid Waiver” concept emerges.

6. Expanded Legal Protections for People with Disabilities 1990s: The ADA and Olmstead Mandate

7. The Congressional Motivation for the ADA…. “historically, society has tended to isolate and segregate individuals with disabilities, and, despite some improvements, such forms of discrimination against individuals with disabilities continue to be a serious and pervasive social problem.” • 42 U.S.C. Section 12101(a)(2).

8. Americans with Disabilities Act (ADA) • Signed by President George Bush in 1990. • The ADA is a federal civil rights law for people with disabilities. • It covers employment, state and local government services, public accommodations, and telecommunications for the deaf. • The ADA is designed to remove barriers which prevent qualified individuals with disabilities from enjoying the same opportunities that are available to persons without disabilities.

9. There are Five “Titles” to the ADA • Title I: Employment • Title II: Public Services • Title III: Public Accommodation • Title IV: Telecommunication • Title V: Miscellaneous

10. In 1999, the Supreme Court of the US held in Olmstead v. L.C., that under Title II of the ADA, states were required to eliminate unnecessary segregation of persons with disabilities and to ensure that persons with disabilities receive services in the most integrated setting appropriate to their needs.(extracted from ADA.gov)

11. Renewed Enforcement 2000s: Both the Bush and Obama Administrations Promote Initiatives that facilitate transitions to community living, including: • New Freedom Initiative • Money Follows the Person • Expanded federal collaboration between housing, disability and Medicaid partners • Year of Community Living • Increased oversight and enforcement activity by the US Department of Justice • Recognition of the role of Housing in LTSS

12. Transitions to Community Living Supportive Community Based Housing

13. Federal Focus on ADA and Olmstead • US DOJ findings letter • The State’s prioritization of investment in institutional settings at the expense of community-based settings; • Many individuals with mental illnesses continue to live in long term care settings because there are not yet more appropriate alternatives available to them in their communities

14. State Response • On August 23, 2012 Acting DHHS Secretary Al Delia signed an agreement with the US DOJ to settle claims that the state of North Carolina had violated the American with Disabilities Act with respect to individuals currently residing in Adult Care Homes and state psychiatric facilities who were considered to have severe and persistent or serious mental illnesses.

15. Who is the Priority for the Settlement Individuals who are living in adult care homes who have a diagnosis of serious and persistent mental illness. Individuals who are referred to adult care homes with a diagnosis of serious mental illness Individuals who are in treatment in a state hospital. Individuals living in the community who have diagnosis of serious mental illness who are eligible for ACT or Supportive Employment

16. Individuals who are priority for 2,000 Housing Slots • A) Individuals with SMI in an IMD Individuals who have moved because of a determination of At Risk to be an IMD • B) Individuals with SPMI who are residing in ACH licensed for at least 50 beds and in which 25% or more of the resident population has a mental illness; • C) Individuals with SPMI who are residing in ACH licensed for between 20 and 49 beds and in which 40% or more of the resident population has a mental illness;

17. Individuals who are priority for 1,000 Housing Slots D) Individuals with SPMI who are or will be discharge d from a State psychiatric hospital who have LOS greater than 90 Days or 3 or more admissions in 1 year E) Individuals diverted from entry into ACH after the PASRR screening

18. Housing Specialist Position Development of Housing Opportunities for Consumers DMH/DD/SAS funds a Housing Specialist Position at each LME/MCO Purpose: - Increase consumer access to housing opportunities - Housing Plan / Updates - Housing Coordinator Activities

19. Act as a resource for housing for consumers that are the responsibility of that specific LME. Working in collaboration with DHHS staff to increase supported housing opportunities to persons with mental illness, intellectual developmental disabilities, and/or substance use disorders. Increase ability to access housing options with focus on community integrated housing with an array of accessible treatment services and recovery supports. Role of a Housing Specialist

20. Involvement with local providers Networking with local Continuums of Care Maintaining Bed Availability Data Base Consultation with Care Coordinators How is that achieved?

21. FTE position dedicated solely to housing activities Collaboration with DHHS staff in recruiting landlords in the private market. Ensure Pre-Screenings are conducted Utilize expertise to minimize barriers to accessing housing. DOJ Response Expectations

22. 5) Facilitate coordination of move in activities: A) Inspections B) Applications C) Utilities D) Access to resources Expectations Cont:

23. 6) Reports of findings for consumers maintaining their housing 7) Collaborate with LME clinical team for services 8) Recertify consumer income 9) Help resolve tenancy issues Expectations Cont:

24. Key Housing Components of Settlement Agreement 3,000 people over 8 years Preference for single occupancy 1 bedroom units May mean very affordable 2 bedroom units Maximum 20% required saturation in a community Current NC options are 10% or 100% required saturation

25. Key Housing Components of Settlement Agreement NO licensed housing options Roommate with informed choice DOJ is not expecting many to make this choice Tenant Based Rental Assistance (TBRA) Like Section 8 Housing Voucher Program Tenancy Supports Non Clinical Supports

26. Supporting Access to Housing Targeting Program and Key Rental Assistance

27. What is the Targeting Program? • Partnership between Department of Health and Human Services (DHHS)/Division of Aging and Adult Services (DAAS) and North Carolina Housing Finance Agency (NCHFA) • Annually, 10% minimum up to a maximum of 20%, of newly funded Low Income Housing Tax Credit (LIHTC) units are targeted to persons with disabilities • Individuals are referred by community, state and local agencies • Housing with access to supports and services (on-site services not required)

28. Targeting Program Goal Connect Extremely low-income persons with disabilities who are receiving supportive services to housing that is: • Affordable • Permanent • Community Based • Independent • Apartment Type Setting

29. Key Assistance • The Targeting Program and Key assistance was designed by DHHS and North Carolina Housing Finance Agency • The key assistance is the State funding source that provides the subsidy to make the units affordable • Subsidy is paid directly to the property by North Carolina Housing Finance Agency

30. Key Assistance Eligibility • Household is headed by an adult with income based on his/her disability (Supplemental Security Income (SSI), Social Security Disability Income (SSDI) or Veteran’s Benefits) • Total gross household income is at or below 50% Area Medium Income (AMI) • Household income is a minimum of $300 per month • Household meets the minimum household size per unit sixe standard

31. 1,111 units being served with key assistance on September 30, 2015 • 305 developments in 71 counties • $234 average rental assistance payment

33. Questions? Ellen Blackman, Regional Housing Manager 919-855-4992 ellen.blackman@dhhs.nc.gov

34. MFP and Long-Term Care Transitions

35. Where We Fit In…. Renewed federal effort to support and enforce Olmstead Compliance MFP Transitions to Community Living (DOJ)

36. What is MFP? A beautifully simple concept…. An opportunity to support people to transition into their homes and communities.

37. The Realities of a “Beautifully Simple Concept.:”

38. MFP: 2 Primary Purposes • Support the transition process • Systems change: • Increase Home and Community Based Services • Eliminate Barriers • Continued Provision of Services • Quality Improvement If we only support people to transition, we’re only doing half our job.

39. A Quick History Lesson • A Public Initiative and a Community Effort • 2005: MFP legislation • 2007: NC awarded • 2009: Transition services begin • 2010: MFP extended under ACA • To date, nearly 600 individuals have transitioned.

40. MFP – Who do we serve? The MFP Demonstration Project will transition qualified individuals from qualified inpatient facilities to qualified residences in the community. What does this mean?

41. MFP – Individual Level “Qualified Individual” • Currently track three population groups: people with physical disabilities, people with I/DD and older adults. • Currently resides and has resided for at least three months in an inpatient facility (nursing facility, developmental center, ICF/I-DD, hospital) • Is receiving Medicaid benefits for inpatient services furnished by the inpatient facility, and • Continues to require the level of care provided by the inpatient facility.

42. MFP – Individual Level Qualified facilities include: • Nursing facilities • Developmental Disability Centers (State Operated Centers) • Intermediate Care Facilities for Persons with I/DD • Acute Care Facilities • PRTFs • NOT Assisted Living Facilities

43. MFP – Individual Level Qualified residences in the community include: • A home owned or leased by the individual or the individual’s family member, • An apartment with an individual lease, with lockable access and egress, and that includes living, sleeping, bathing, and cooking areas over which the individual or the individual’s family has domain and control, and • A residence in a community-based setting in which no more than four unrelated individuals reside.

44. NC MFP’s Benefits to the Individual… • CAP/Innovations slot or PACE participation • Project pays for first year, becomes regular CAP slot afterwards. • Start up funding to assist in transitions • Broadly construed: furniture, ramps, services (like therapeutic consultation, staff training, etc.) • Additional case management • Transition coordination support

45. MFP on Page Moves back into community with Supports Long-term resident moves OUT of a nursing facility, hospital or other qualified facility MFP Transition Supports

46. What Does “Community with Supports” Mean? • Has personal support and case management services. • Has natural supports (i.e. family) needed to meet critical support needs not covered by paid services. • May have additional supports related to supplies, adaptive equipment, home modifications. • Remains eligible for services so long as person meets requirements.

48. Not just a NC Challenge…. (Mathematica Policy Research, Housing Challenges Reported by MFP States, 2014 Findings)

49. Creating a Mutually Supportive Partnership What Participants Need • More accessible units on bus lines. • Flexibility in application process, recognizing the transportation while in facility is restricted. • Examination of alternatives support models (i.e. tele support, alternative living arrangements). • Supports in being quality tenants. What We Hear Landlords Need • Assurance person will receive necessary supports • Individuals respect property requirements • Others?

50. Why This Matters……