1 Cash and Counseling -- Supporting Independent Living. Presenters: Lee Bezanson, Kevin Mahoney, Tim Fuchs and Erin McGaffigan. >> SHARON: Good afternoon everyone. Welcome to today's webcast, Cash and Counseling -- Supporting Independent Living, presented by Lee Bezanson, Kevin Mahoney, Erin McGaffigan and Tim Fuchs. This webcast is being sponsored by the Cash and Counseling National Program Office at Boston College. My name is Sharon Finney and I'm with ILRU. I'll be assisting with today's call. Before we get started, let me cover a few housekeeping issues. Our operator, Jade, will explain the teleconference portion. Jade... >> OPERATOR: Thank you everyone for your patience in holding. At the conclusion of the speaker's presentation, we will open the floor for questions. At that time instructions will be given if you would like to ask a question. Now I would like to turn the conference over to Ms. Finney. >> SHARON: Thank you. For those of you on the webcast portion today, to submit your questions, click on the E-mail button on the bottom right-hand corner of your screen or you can E-mail your questions directly to webcast@ilru.org. If you should have any technical problems today, please feel free to 2 call us at (713)520-0232. Again, thank you all for joining us today. Now I'm pleased to introduce our presenter Tim Fuchs, operations director at the National Council on Independent Living. Good afternoon, Tim. >> TIM: Hey, Sharon. Good afternoon. Thanks. As Sharon said, I'm operations director of NCIL, and I think most of you know what NCIL is, but just in case, I'll give you the rundown. The National Council on Independent Living, which is commonly called NCIL, is a national association of independent living centers and state independent living councils and other IL advocates, the state and regional IL associations and other disability advocates across the country. We were founded in 1982 and we're now in our 25th year and we're excited about that. We're still completely member controlled and we have what I think is one of the most solid grassroots connections in Washington. In fact, we're the oldest grassroots cross-disability organization in the country. And as the independent living representative here in D. C., we've been -- had our eye on and have been excited about Cash and Counseling since it was originally funded in '96, and since the demo programs began in the three original states in '99 really -- New Jersey, Arkansas and Florida. And over the years, a lot of CILs have contracted to provide enrollment services, counseling, and also serve in advisory roles. For those that have not been involved, you know, that's why we are excited to be involved in projects such as today's training. To give people information on how they can and just to encourage CILs and even SILC and all IL advocates and if it is a program in your state, get involved and so 3 you can get your opinions across, connect consumers with funding, you know, and what I'm saying is that there are benefits to be had for consumers and Cash and Counseling participants as well as for the centers. NCIL does support the Cash and Counseling and we're working hard to increase the funding that's behind it and we not only support Cash and Counseling, of course, but any program that is consumer-directed and provides attendant services and other needed services and supports in the home. Unfortunately, it's also our view that without sufficient funding, even the best consumer-directed programs can be limited. We do, of course, applaud and are very supportive of the shift away from the medical model and institution Al care, but again point to the fact that consumers can only do so much when there isn't enough funding regardless of where or how they get it. And it's certainly not the fault of Cash and Counseling, but I think it's something that becomes a primary concern when we consider niece sorts of home care where the philosophy is sound, but we simply need more money and it's state by state, so it's difficult to track, too. We love the flexibility of Cash and Counseling and the fact that benefits may be used not only for attendant services, but for assistive technology, home modifications. And, again, this is an advocates point of view and I'm trying to relate some of the difficulty encountered and the frustration with funding available in particular states, but I do need to mention the success that many CILs and consumers have met with Cash and Counseling, whether program participants or, again, CILs contracting with a state to enroll consumers or provide counseling and advice. And that in 4 some states participants are receiving strong benefit and also in those states the satisfaction rates are extremely high. But I want to get to the bulk of today's presentation which is to provide information on Cash and Counseling and let you all know how you can get involved if you're not already; but I want to say that I also see today's call as an excellent opportunity for us to get feedback and so I just want to say before we move on that if you would, please let us know what your encountering with your state and how you feel about the program and you can write to me directly and me I. mail address is Tim@ncil.org and you can always visit the NCIL website for my contact information and also for the contact information of Elizabeth NCIL's health care policy analyst who tracks information and progress on Cash and Counseling. Without further ado though, I thank everyone for joining. I really want to thank our presenters today and I'd like to turn it over now to Kevin Mahoney. Kevin... >> KEVIN: Thank you, Tim. We certainly appreciate the chance to meet and talk with independent living centers across the country. There is no doubt that the whole Cash and Counseling approach which amazingly enough I've had the pleasure of working on for 12 years, but it is no doubt about how it grew out of the independent living movement and how, you know, visions are so akin to each other and the role that independent living centers have played in this growth, you'll hear more about today. I know in the early days we had the chance to work actually closely with (inaudible) whom many of you I'm sure remember as far as, you know, writing and working with the independent living centers as we tried to 5 develop the whole idea. And it's just the chance from the beginning to say thank you to the people at NCIL and the people at ILRU, you know, for the assistance and support and feedback we've been getting. What I hope to do in the next 15 minutes is sort of ambitious, but it's to try and just so some of you may have some of this background already, but just to try and evenly bring people up to date to talk a little bit about the Cash and Counseling history, the basic character it's sticks of the model and the research findings you know which are so supportive of the vision that we are all working on together. So that's my goal. Basically, today in most states it's still true, whether you're elderly or a person with disabilities that if you need help with such basic things as bathing, dressing, getting out of bed, you rarely have a choice about who helps you, what time of day you have to shower or get out of bed and receiving care from agencies there is often some important restrictions on what people can do. So the starting place of Cash and Counseling was people across disability communities saying if I had more control of my services life would be a lot better and I think I can do it for the same amount of money, maybe even a little less. And it's literally those contentions of the disability community, Cash and Counseling was set up to be really a policy driven test of those contentions that with consumer direction people's lives would be better and they could do it for the same amount of money. Before I even get into the slides I'll say this: In one sense -- there were four things that we saw, anyway, as somewhat unique about Cash 6 and Counseling. The first was that we really wanted to test this whole approach on a large scale. We knew that for many people they'd say, oh, you know you can hand pick a small number of people, but basically Cash and Counseling -- the original demonstration was tested with three states of Arkansas, Florida and New Jersey. And it was tested with 6,700 people. So that was the first thing we wanted to test this on a large scale. The second thing is we really wanted to test it with the most rigorous scientific evaluation that we know how to do. I mean, the problem, you know, if you put yourself back in the mid '90's was you said Cash and Counseling and people said fraud and abuse or self-neglect or we had a belief that unless we could test it in a way that people could see, you know, the results, that they wouldn't still believe and so the way that this was tested and evaluated was of the 6,700 people literally half of them were randomly assigned to stay in traditional agencies and half got to manage, you know, a budget equal to what the agencies would have received. And that's really the third thing that was at that point unique or somewhat unique about Cash and Counseling and that was if we were going to have the chance to test this idea, we wanted to use one of the more ultimate forms of consumer direction, and so literally the Cash and Counseling model is one where the participant is given control of and can manage a budget roughly equal to what the agency would have received on that individual's behalf. So we wanted to test one of the more ultimate forms of consumer direction and the fourth thing that I'd say was sort of unique is we were looking for a model that really could work or be tested across age groups and across different types of disabilities. So even the 7 original Cash and Counseling Demonstration was involved elderly, adults with physical disabilities and children and adults with developmental disabilities. So now I'll sort of launch into some of the brief history of Cash and Counseling and for those of you, you know, that are following along, I'm going to move to the PowerPoint that says No. 2. Basically Cash and Counseling got underway you know just as Tim has told you, we sent out the original calls for proposals in 1996, amazingly enough. Right from the beginning, it was a partnership between the Robert Wood Johnson Foundation, you know, which is the largest foundation in the United States that really focuses solely on health and health care. They partnered with ASPE which is the Assistant Secretary for Planning and Evaluation at the federal department of health and services -- Health and Human Services. And most recently they partnered with the agency on aging. All of the original Cash and Counseling work was done for people who were on Medicaid, and that has definitely been the focus. As some of you know, most recently the Administration on Aging, with the reauthorization of the older American's act are sort of applying this idea to people above the Medicaid level as far as income and assets, but in all of the original years we worked very closely with the center for Medicare and Medicaid services, so much so that believe it or not I probably met with them every two weeks for ten years, which hopefully has paid off because in so many ways we have adopted this approach and built it right into the -- like now if you apply for a 1915c waiver. We at Boston College school of social work have had the privilege of 8 being the national program office and what that means is we've sort of coordinated this whole effort, provided technical assistance to the states, and overseen the valuation and later on you'll see all of the research results, the whole quantitative part of the evaluation was done by Mathematica Policy Research and for those of you who are interested in more of the stories, the effects on people's lives, there is also a qualitative part of the evaluation that was done by the University of Maryland at Baltimore county where we followed 25 people and their family and counsel ors in each of the three original states so these 75 stories of how it affected people's lives are also up on our website which I'll mention numbers of times, but it's easy, www.cashandcounseling.org that you can see all those. Going on to the next PowerPoint, as I mentioned the original states were Arkansas, Florida and New Jersey. Arkansas got going in November -- December 1998. New Jersey, November 1999; and Florida, in May/June of 2000. And in all of those states, Cash and Counseling clients involved the elderly and adults with physical disabilities. Florida, it also included 1,000 children with developmental disabilities and amazingly once Florida got up and running, it only took about three months to recruit those 1,000 children. The feeder programs -- what that means is in Arkansas and New Jersey the ability to manage a budget was an alternative to receiving your Medicaid state planned personal care whereas in Florida it was an option -- it was an alternative to three different 1915c -- the whole home and community-based service waiver. 9 What Cash and Counseling -- one of the beauties of this, you know, is it can adapt to every state -- states being different than Medicaid benefits, their delivery system, their culture, their politics, but what I've found over time is it's very useful if I talk about the basic model that's the same across states and I've got it down to five steps and one important anecdote. What I'll try and do now is walk through that. In step one, the participant enters the long-term care system much as they do today. You know, they really get the traditional assessment and care plan, whatever it would be in your own state, but step two then becomes a very important one. In step two, a dollar value gets assigned to the care plan that that individual would have gotten in that state, you know, for equity purposes it's really an attempt to say what would this individual have gotten for a care plan in this particular state? So, you know, the care plan certainly survey ed significantly across the different states. The whole issue of how that dollar value is assigned is something I'd be glad to talk about more in the question and answer period. It differs by state, but if someone's needs are consistent, some states have used their expenditures over the last six months. If they are brand new or needs are fluctuating, states more often have used the care plan. Sometimes they have ee had to adjust the care plan knowing the full care plan is rarely delivered in every state, but step two is basically simple. It's a dollar value assigned to the care plan that individual would have gotten. Step three you'll also hear from some of the CILs -- particularly I think Rhode Island -- this is an also. Consumers often with their families 10 if they so choose or people that are important to them receive enough information to make a choice about what's best for them. We've never seen Cash and Counseling as being for everybody. It's an alternative. It's one that makes a big difference, you know, for some people; but to sort of accent the fact that this is a choice in all the Cash and Counseling states and for all Medicaid Cash and Counseling programs alike, it's very important that the person has the right to return to the traditional system at any point, and in some of the states they've really tried to work it out so that they can consumer-direct some of their services and others they could still receive from the traditional agency. Step four, is one I'll spend a few moments on. Cash and Counseling isn't really like an SSI benefit. It's not just sending out the cash. Right from the beginning in every state there was agreement that the person would have to develop a plan, a spending plan for how they wanted to use the budget. And the basic litmus test in every state -- where states operationalize this different. Some have long lists of things that are clearly a and others you have to go through an exceptions process; but the basic litmus test is the item the participant wants to spend money on helps address their personal assistance needs, that it's tied back to their personal assistance needs, that it helps them remain independent in the community. That's the basic litmus test. So, you know, basically people are able to hire a worker of their choice. In most, but not all of the Cash and Counseling states, people can even hire legally responsible relatives such as parents of young children or spouses. People can also spend that money on a whole range of assistive 11 devices, home renovations, a range of goods and services that would help them to be more independent. You know, ranging from a woman with MS in New Jersey who, you know, might need a chair that's hard enough that she can get out of, or a man in Arkansas who is blind with diabetes who used to have to go to a laundromat in an unsafe area used some of his money to buy a washer and dryer. So that's step four, a plan for using -- a spending plan. It varies by states, but in some of the states that have used the new state plan option, they are even able to give out small amounts of the money in cash. Step five is another area that's a major Hallmark of Cash and Counseling and of many, you know, other forms of consumer direction, but it's the participant isn't left on their own. They have available to them some key supportive services; one, the fiscal management service is basically a bookkeeping/check writing/tax paying service. The other one that's sort of crosses states consistently is a counseling or support broker or consultant service. It's named differently in different states, but instead of a care management professional knows best medical model, it's much more of an empowerment model to help people think through, you know, the most creative or efficient ways to meet my needs. How do I develop a spending plan? How do I find those resources like workers? How do I develop a backup plan? How do I train my workers? How do I fire my mother? Certainly those supportive services -- we were very lucky that we had funding from Robert Wood Johnson Foundation to do focus groups and survey representative people in each of those states. And we learned ahead 12 of time what kind of supports people wanted and that in a sense was a real part of the consumer-directed planning of Cash and Counseling. The important anecdote that I want to say is we learned -- we had tremendous interest, I won't say pressure, from for instance the Alzheimer's Association and they were saying in the past consumer direction has been limited to people who could fully manage on their own. And, gosh, people with Alzheimer's have strong preferences. There is times they could really benefit from an individualized plan so they could have consistent workers or a safer environment and is there a way we can participate? And I was lucky enough to be doing some joint site visits with Tom Nerney whom many of you know from the self-determination projects and we borrowed heavily from the developmental disabilities community the idea of someone being able, you know, to appoint a representative who can help them manage and can help make decisions on their behalf. So that's the basic model. For those of you who are lucky enough to be able to see some of the PowerPoints, PowerPoint 6 shows not only the three original states of New Jersey, Arkansas and Florida, but it shows we were lucky enough -- the research results that I'm about to summarize for you, we were so beyond our highest expectations that the Robert Wood Johnson Foundation and funders at the federal department of health and human services gave us funding in 2004 to add additional 12 states and those additional 12 states: Washington, New Mexico, Alabama, Minnesota, Iowa, Illinois, Michigan, Kent, West Virginia, Pennsylvania, Rhode Island and Vermont all received three year grants and amazingly enough, Pennsylvania will be the last state to implement, and their target is I think in an area of 21 counties in 13 Pennsylvania. Their target is November 1st to implement. So basically we're pretty proud to say that all of these 15 states will be up and running. Most of them statewide, but some of them in particular areas that you can again see what areas they are running by looking at Cash and Counseling.org, our website. Our research results, I'm just looking at my time -- what I've really tried to do is highlight some of the ones that were the most important. And for those of you who printed out these slides, I'll spend a minute telling you sort of a way to read them. We've separated results for the nonelderly, the elderly and children. The key -- the treatment group are those people who got to manage the benefit themselves. C., the control group are the people that stayed with tradition ago agencies and we've separated results by each state. Arkansas, Florida and New Jersey. What you can basically see is the pattern is always the same here. You'll see this across all of the slides. It's the first message across populations and states the results looked a lot alike. This first PowerPoint is one of the most important results. We asked people nine months after they entered the program, did you get any personal assistance services in the last two weeks? And if you look at Arkansas' nonelderly, you see a really important result. You see that 95 percent of those who managed the benefit themselves said yes, whereas only 68 percent -- only about two-thirds of those in the control group said they got any personal assistance services in the last two weeks. Look at elderly in Arkansas, again, 94 percent of the elderly said we got services in the last two weeks 14 as opposed to like only 80 percent, 79 percent of those in the control group. So be it that some of these states had worker shortages, especially hard and rural areas or inner cities, be it that people could tailor the benefit and bring in people that had a special relationship with them who might not have been in the workforce, access was dramatically improved. We then had four measures of quality of care and just to give awe preview, one of them was how satisfied are you with various key aspects of your care, like did the worker come on time? Did the worker treat you with respect? Second measures were unmet needs. The third set were health outcomes and the fourth was total life satisfaction. And I'll go through these quickly because you have the chance to look at them at your leisure or look at them on our website, but basically -- and remember here, all we're doing is comparing those randomly as signed to the treatment versus the control group. What you have are just Astro nomic differences in how satisfied people were with their overall care. This Randy Brown from Mathematica who headed the research team said in all of his 30 years as a researcher he had never seen results like this. The same when you look at unmet needs for care, again, you can see the patterns, the same across states, but dramatically different less unmet need. The third area, health outcomes, I'll go a little slower here because many people really wondered -- and remember this, all the comment you'll hear about fraud and abuse, all the comments you'll hear -- we had no major incidents of fraud and abuse in the time that this has been up and running, but all of the comments of the people will be untrained -- this is again 15 one of the more important findings. We had 11 measures of health outcomes that included bed sores, ulcers, contractures, falls -- I just happened to show the one on contractures, but here is the point of these 11 measures of health outcomes across seven populations, never did the traditional agencies in a statistically significant way scored better than people who managed on their own and in about a third of the measures not only did the people who managed their own benefits do better, they do 20 to 50 percent better. The last quality outcome we used was overall life satisfaction and this may sound like sort of a boring measure, but you know for those of you with a research background, you know this is a measure that's hard to move. And not only again you see the consistent findings, but people were much more satisfied with their lives overall, but if you think about Arkansas where the average benefit for consumer was in these years, the early 2000's, the average benefit was about $350 a month, just imagine that that was enough to have that kind of effect on people's overall life satisfaction. We don't know even a way -- is it because they had control? Is it because it was more flexible and they could adapt it? Was it because they were more tied in with their families and communities because they could use the money -- my easiest example is a man in Minnesota who had even stopped eating pretty much, but when he found he could hire a worker, he could do his grocery shopping next door to where his wife was in a nursing home and he could see her, he started thriving again. The effects for caregivers were equally positive. That's the slide 12. Kaye givers had last financial and emotional strain and you can see 16 the overall satisfaction in their lives. We also had a part of the evaluation comparing the experiences of workers and suffice it to say in New Jersey and Florida when a consumer got to choose how much they wanted to pay the worker of course they always had to pay the minimum wage, but when the consumer had the choice, they paid a dollar more than the agencies just for example. The workers the consumers hired felt better -- they felt more better recompense than the agency workers, albeit many of them didn't get anything at all before. They felt equally trained. They had fewer accidents themselves, but the other thing going very quickly, we also wanted to look at effects on costs and we were pretty Leary about costs because remember that original research result I showed, you know, basically it was saying in the traditional system, large numbers of people weren't getting the prescribed care that was in their plans of care. Basically we looked at costs for -- PCS means personal care services. We looked at all other Medicaid costs and we put them together. As far as for personal care costs, it costs more for the personal care and why? Mainly because the control group wants getting the care that had been authorized; but when we look at nonpersonal care costs like hospitals, nursing homes in all three states it was lower and just a few facts to catch your attention and that you might want to use with your own legislators, Arkansas had 40 percent fewer admissions to nursing facilities in the second year for treatment compared to the control or we have a whole article in publication called medical care that shows when we got a third year of cost data from Arkansas, there was an 18 percent drop in nursing facility costs. So overall when you looked at costs, you have a state like Arkansas 17 that was a break even statistically speaking because the big savings on institutional costs offset the increased costs for personal care. The other states had small but modest cost increases, but what we really believe -- and this is also on our cash and counseling.org website, we learned a lot of implementation lessons about how to contract for like the supportive services, how to do outreach in more efficient ways and so we basically believe states can achieve all of these results basically for the same amount of money and this is my last PowerPoint, they can increase access to care greatly improved quality of care and caregivers benefits and the states don't need to be concerned about costs if they pay attention to, you know -- so I don't know if I should pause for questions or if I should turn things over to Erin McGaffigan to talk about the participant role? >> SHARON: We do have a couple of if Erin would like to pause for a minute. I have a couple of webcast questions. And Jade if after I ask these questions if you could ask the teleconference audience and give them the cue. >> OPERATOR: Yes, ma'am. >> SHARON: I think we'll try that for now. Kevin, the first question is do all states have a Cash and Counseling plan? >> KEVIN: No. At this state -- at this stage there are 15 states that we have worked with, you know, and those are the ones that are on that map that people can access, but you can also go to Cash and Counseling.org, our website, and you can literally click on any state and see is the whole state covered and who are the contact people. 18 There are a few states that are beyond Robert Wood Johnson ones that have implemented Cash and Counseling like Oregon or modest size programs in the Carolinas, but truthfully now the federal deficit reduction act allows every state to offer this Cash and Counseling option without having to do waivers under that new section 1915j, one of the reasons we were hoping to have this webcast was for states to know, you know, there is the ability without waivers to do this in your state and we'd like to talk with interested CILs and advocates who would like to see such a thing develop in their own states. >> SHARON: Great. Now, can you explain how a consumer might apply for that Cash and Counseling if they have it? >> KEVIN: Well, let's see if I understand. If you're in a state, you know, where Cash and Counseling exists, you know, the first thing to look at is is it the whole state where you're eligible? Like in Michigan, this got started in the Detroit area, the three counties around Lansing, the southwest corner of bat on harbor and the upper peninsula. So over this year they are opening it up to the whole state, but if you're on Medicaid, you're at least 18 years old, you're a recipient of either waiver or personal care services, you know, then that state should have an 800 number you can call or you can ask through your Medicaid program care manager how do I get on this? >> SHARON: Thank you. Jade, do we have any questions from the teleconference audience? >> OPERATOR: Okay, if you'd like to ask a question, please press star 1 at this time. Again, that's star 1 to ask a question. 19 We do have one from Marvin with Brookman Center. >> CALLER: Yes, I know that New York was more or less an (inaudible) of the Cash and Counseling programs, supposed to be one of the first states to implement it, but I understand it gets turned downtime and time again. Do you have any insights on why this is happening and what we in New York can do to get it established here? >> KEVIN: That's a great question. Sad to say, of all the states that we've worked with, New York is the only one that we did not succeed. Part of it I think was -- this is my own point of view -- was, you know, New York State was very decentralized at least at that point in time with the local social service districts having such great power or influence. Off the record, I'd say we almost wish we had given some grant to New York City because such a large proportion of the people were there. I know that there remains interest in certain parts of state government and the legislature and that's where I would push forward. I know that on the elderly side New York did apply for -- as I say the Administration on Aging just put out grants for states interested in developing home and community-based services for people above the Medicaid level who are at risk of going into a nursing home and spending down and I know New York is one of the states that got that and I think they would not -- I think they were a state that has a chance of not starting in 2007, starting in 2008. And I think it's Oneida County. And again, my personal feeling, too bad they wouldn't want to try it on a larger scale. >> SHARON: Are there any other questions? >> OPERATOR: Thank you, sir. Our next question comes from Mary 20 Ann with Cash and Counseling from Pennsylvania. Never mind. She disconnected herself and we do have a question from Geraldine. >> CALLER: Yes, I understand okay this is pertaining to individuals who are Medicaid already on Medicaid? Does it also apply to individuals who are above the Medicaid standards? >> KEVIN: Okay, let's see. Let me be very precise. Cash and Counseling really started as a Medicaid option. >> CALLER: Right. >> KEVIN: And each of the states that we highlight on our map, you know, have this through their Medicaid programs. The only place that I know of, you know, where the movement is afoot to expand this to people above the Medicaid, first of all, are these Administration on Aging grants that just got awarded the beginning of this month to 12 states to start this year and eight more in the following year and that's focused on the elderly. But some of these states are also applying this to their state-funded programs. So like those of you like in Illinois, for instance, on the elderly side there is literally a state-funded entitlement, you know, for a modest amount of home and community-based services. I know Illinois is moving to introduce this option even into their state-funded program. And there are a handful of other states moving that way also. Some states are also trying to apply it to things like their Alzheimer's disease respite programs. >> CALLER: Okay, thank you. >> OPERATOR: Thank you. Our next question comes from 21 (inaudible) with Liberty Resources. >> CALLER: Hi, good afternoon. You had mentioned that Cash and Counseling would give consumers more choice in who they hired for their personal assistant services. Did the three states in the original study have a consumer employer option? Pennsylvania has one so I was wondering if that comparison was made in states that did not have the option where consumers could already hire who they wanted as attendants? >> KEVIN: Sure. Okay, let me again be precise. The original three states, to the best of my knowledge, consumer direction was brand new to those states and in the sense that really -- you know, like it was a good place therefore to test the efficacy of giving consumers control. So, I mean, for instance, we didn't use a state like California where people already had the ability to hire and fire their own workers and maybe 300,000 people and it wouldn't have given as much of a chance to demonstrate these amazing results. Now, of the 12 new states, some of them like Pennsylvania or Vermont or I could go through quickly in my head people already had the ability, you know, to hire and fire a worker. So what Cash and Counseling added was truly this idea of consumer control over a whole budget so that they could also use the money flexibly to renovate homes or buy assistive devices or a range of goods and services. So in the next round of states where people already had some level of consumer direction we're also trying to look very carefully at -- we have on whole project to sort of isolate what are the additional benefits of that increased flexibility. >> CALLER: Thank you. 22 >> OPERATOR: Okay, thank you. Our next question comes from R. L. with accessible and universal design research. >> CALLER: Hello? >> OPERATOR: He disconnected and we have one more question from Mary Ann. >> CALLER: Can you hear me now? >> KEVIN: Yes. >> CALLER: I apologize for earlier. I was so excited you called on me, I turned a corner and I dropped the phone. I am attempting to help Pennsylvania foster along its process of Cash and Counseling and we are more -- many of us strike Pennsylvania with Alabama and Pittsburgh and Philadelphia on either end. I guess my question really becomes when you have a state that is so diverse as ours where you have rural and big city, any suggestions or guidance? I know rural consumers are -- from the reading I've been doing fare better when its comes to being taken care of with cash and kon sedge, but how do we explain this to legislators when we have such a mixed bag as a state? >> KEVIN: That's a great question. You know, Pennsylvania is also from my understanding one of the states -- many states are very diverse, but Pennsylvania also has a very decentralized approach where, you know, my understanding is it's area agencies on aging that are taking the lead and they have a significant amount of say so and I think that partially explains why it takes longer you know to implement in a state so big with such diversity. I think the best way, truthfully -- you know, I wanted to arm you with 23 these kind of research results and statistics because those stand out to certain people and certain legislators want to see that this won't cost additional and you could get so much more for your money as far as access and satisfaction. Truthfully, I think most people, what it comes down to is what they want to hear are stories from the local area. And they want to -- you know, we found that like with peer support, with people who had wonderful results who were either willing to have their stories told in local media or be available to people who are trying to think out does this work for me? You know, even some 85-year-old women in Arkansas said I really like to be able to have people call me if they are trying to decide to do this. So I mean my short answer to a longer question is I think people come to see how this works when they hear about people like themselves. >> SHARON: Are there any other questions? >> OPERATOR: Okay, thank you. We do have a question from Tim with Placer Independent Resource -- >> SHARON: If this could be our last question I think we're running a little over. >> CALLER: Hi, I was wondering if you heard or you knew if California was going to be starting this and the second part of that was does somebody already have to be in a home to get these services available? >> KEVIN: Okay, let's see if I follow the question. California to my knowledge has not, you know, applied or started to implement this additional effort of the flexible budget that people can, you know, creatively tailor to their own particular needs. California, on the other 24 hand, has the largest, you know, public program where people can at least choose their own workers. So that's to their credit. Let's see, the second part of your question -- could you repeat the second part? >> CALLER: You were states in the five steps like the first step was if they were in a home, then they would be assessed as far as a dollar value of how much it would cost to keep them in there and they would get -- be allotted that amount to be able to stay in their own home. So can they access that before they get to the point where they are in a home? >> KEVIN: Well, maybe I wasn't clear. Where people access this is in their own homes, you know, not in a nursing facility, not in a congregant type of facility generally. So let me see if I can bring it to life. If I am in let's say in Arkansas and living in Little Rock or living out in one of the more rural communities, if I'm living in my own home and I have needs for personal care, and I'm on Medicaid, then this should be a choice that every one of those people is given. We've been really adamant that where it isn't for everyone, everyone should be given that opportunity to think it through, especially since they can appoint a representative to help them. Many states -- for some states you have to already be receiving Medicaid home care, but in other states even when you first apply for waiver services or personal care services right from the beginning this is one of the choices that you're given. And that's the way they did it in Arkansas that helped them get such change, you know, and less nursing home 25 use. >> CALLER: Okay, thank you. >> SHARON: Thank you. Let me before Erin begins just say for those of you that are joining us today if you'd like to E-mail a question, you can E-mail it to webcast@ilru.org. And Erin... >> ERIN: Thank you very much. I'm going to talk very briefly -- my name is Erin McGaffigan. I work with Boston College around participant involvement strategies. As early as this last spring of 2007 we developed what is called a national participant network and I'm starting on slide 17 for those who have slides in front of you. The national participant network was really our opportunity to ensure open communication across representation across the states of participants and caregivers to give them the opportunity to learn from each other about the existing ways in which participants are involved in the design and improvement of programs, but to also recognize that not only it being a self-directed program, but in that therefore program design implementation should have participant involvement in that as well. That the recognition also in addition to that that advocacy obviously for it to be most effective would be driven by the participants themselves as well. So we took this opportunity to develop a national participant network where we requested that each state that has a Cash and Counseling program identify one to two individuals, participants and caregivers, recognizing that representation would be helpful in both areas, and we requested that they come together once a month to discuss specifically as you see on slide 17 idea toss make Cash and Counseling better, but also to identify ways to 26 increase advocacy for the model and to ensure its stability over time as well as increase participant involvement in the actual program itself. I'll talk more about that in a few slides. If you go to slide 18, these are the two guiding principles of the national participant network, one was just an assumption that participant involvement in all areas of the program itself and 2 design, implementation and evaluation will be to a better program. It's not just about directing personal assistance services, but making sure the model itself is really directed by the needs of the individuals it served. And then the second one participant involvement is critical to make sure our programs are available in the future. As we know, it takes quite a bit of advocacy to make some systems change and it's really important to have that grassroots level involvement in understanding or involving them in how to advocate for themselves. So slide 19 tells you a little bit about our process today, with this national participant network has been doing since the spring. We had our first kick-off meeting in June of 2007. As I said, we meet monthly. We meet by teleconference. The calls are about an hour. We're having some discussions now but that seems pretty short. Also our representation knowing that people are actual participants, but sometimes they may or may not be able to attend our calls. So we're challenged with the reality that people have lives and it might be complicated to participate, but right now we have approximately -- it says 11 on your slide but we have 12 to 15 states represented and we're sure we'll get representation across the board soon. It's still pretty early and it's also taken some time to get people 27 up to speed. We have quite a diverse range of experience on these calls. Some people who are coming who are participants who just started the program and have little to no direct experience with advocacy and then we have others on the call who have been advocates in their states since the design of the programs and even prior to that. So we have a real diverse range of group of people on these calls which has been an excellent opportunity to really share some great information and resources. As I said, we have participants and caregivers on the call and we probably at this point have about half and half. The next slide is slide 20. This gives you a little bit of an idea of what our topics have been for the national participant network. As I said it's pretty early in the process and we're trying to get to know each other, but really we're talking about now existing approaches in which programs are involving participants in the design and improvement of their programs. So we're learning some great states like New Mexico who are having a great deal of designing programs and has been integral in the development of their models. So we've had those discussions and leadership training -- we had a leadership training last month actually with the sup object of ILRU to assist to provide a baseline of level of information about advocacy and advocacy involvement. And then we've had -- what's interesting is we've had an open discussion. We spent most of our time on these calls discussing specifically around the two goals I identified for you earlier, participant involvement and advocacy, but really to people to recognize to become strong advocates within their program and within the model they really need 28 to get what's going on in their state, but in addition to other states. So people are spending about 15 or 20 minutes or so of the call just in open discussion about what's happening in the states and where can they go to get more information. Now, what I did not say in the previous slide was that the agendas -- we have four individuals who work with us every month to draft the agenda and facilitate the calls. So I wanted to make sure I said that as well. And what I was saying with the open 15 minutes of discussion, what has interestingly come up is some of the ideas about recruitment strategies, people are very interested to know how states are helping or assisting individuals who recruit workers so there has been a lot of creative resources shared and methods in doing that, training tools and all that good stuff. Hiring spouses has been a topic of interest as well across the network. What's been interesting about the network is it's been a really eye opening experience for the individuals involved to hear all the great things that are happening in other states. So, for instance, in some states you are able to hire a spouse and a lot of the networks are interested in knowing how that works. And then a future topic we hope to really touch upon after we discuss fully the various participant involvement strategies and program design, we really want to then dive into peer support and what that looks like and there is obviously been a lot of connections with the independent living centers that you'll hear about, but a lot of states -- a lot of the participants on the calls could benefit from learning a little bit more about how peer support can be used in this model. 29 So I touched upon this a little, but if you move to slide 21, you will see a broader review of how participants and care delivers are involved in the Cash and Counseling states. For one, they are involved in a lot of program design, a lot of states have planning committees and waiver committees and work groups. What we find is that some of these are specific -- some of these are diverse representation across stakeholder groups, including provider groups and others have specific participant work groups or committees that provide input. That's a little bit different than more kind of a routine advisory panel that some states -- that all states are utilizing, but some are really identifying generic or creating generic committees for many different projects to be reviewed and for them to participate on. And others are creating very topic specific advisory panels. Another interesting method in which participants and caregivers have been involved that's been quite successful has been in outreach. People recognize that word of mouth has really been a strong way in which to increase enrollment of these -- of the Cash and Counseling model, but it's also obvious that the role of the independent living centers which again you'll hear more has been key to that as well. And the assisting -- the assistance of participants and caregivers in the actual development of tools has seemed to be successful in terms of developing brochures or tools that are easy to read and actually meet the needs of participants that are involved. If you go to slide 22, you'll see some more examples of participant and caregiver roles as noted, peer support. In Florida specifically a 30 participant on our network who is involved in a peer support -- a caregiver peer support group -- and then a peer mentoring as mentioned by Kevin, Arkansas had one individual in addition to the more structured peer mentoring that we see provided, there were actually informal assistance where one or two or three caregivers or individuals just wanted to be able to share information with other people about the program and answer questions. Quality monitoring and improvement is an interesting one. For instance, in New Mexico they have developed a quality committee in addition to other committees where participants and caregivers and advocates are having a direct role in quality monitoring improvement. And then you'll hear more about the consumer-directed module which Rhode Island participants have been involved in. And that's all for me. >> SHARON: Thank you, Erin. I believe Lee Bezanson. >> KEVIN: I think the order of the PowerPoints switch en to Minnesota and Rhode Island? >> LEE: I'm next, kef in, but we were going to see if there were any questions. >> SHARON: Are there any questions from the phone lines, Jade? >> OPERATOR: Just as a reminder if you'd like to ask a question, press star 1 at this time. >> SHARON: I have no questions from the web at this time. >> ERIN: If people are interested in knowing who the representatives are in terms of -- or what type of representation we have 31 for each of the states, you know, feel free to give me a call. The communication information is in the back of the PowerPoint. >> OPERATOR: We do have one question from Tonia with the Coastal Bend center for interested living. >> CALLER: Yes, could you give an example of what the quality improvement or the quality control committee in New Mexico -- some of the things that they look at? >> ERIN: Well, they are actually just starting that committee. So I don't think they've gotten very far. The network has just started so I'm just start to go hear directly from the participants themselves what they've been involved in. So it's pretty new on my side. I don't know if Kevin or anyone else wants to jump in on that answer? >> KEVIN: I'll just say two quick things: One of the reports these on our website is called something like managing for quality in a consumer-directed system. And it's a great report that's on our website you could look at, but it also has appendices that talk about the monitoring and quality approaches that each of the original states were using. New Mexico has gone much further and even involved -- you know, is thinking of involving -- they've been involving consumers in what kinds of satisfaction instruments should be used and who should be asking those questions and that's just an example I happen to watch when I was there. >> CALLER: Thank you. >> SHARON: Thank you, Kevin. >> OPERATOR: Thank you, ma'am. We have no further questions at this time. 32 >> SHARON: All right, Lee, I think the ball is in your court. >> LEE: Thank you. I'm Lee Bezanson from the National Program Office and Erin just referenced the consumer direction module which sounds ominous, but it's actually a wonderful tool for communication. One of the findings among the first three states was -- not finding, but a desire to create better communication in the Cash and Counseling programs between the participants and their caregivers, the people that were providing a support role and the people that were managing the fiscal aspects of the program. And so several of the states have participated in creating this consumer software package called the consumer direction module. Basically, it's been Rhode Island, West Virginia, Alabama and New Mexico. And the states have worked collaboratively with our National Program Office to develop this software and it's a software that's going to be available to other states that develop Cash and Counseling and have an interest. And if you move to slide 24 for those of you that have the slides, the functionality of this consumer direction module is an online access for the participant or the support broker or the fiscal agent to a participant's spending plan and an addition to track the expenditures in that plan when a participant wants to change the plan, it greatly expedites their ability to get approval for those changes because people can simply do it online and even get approvals online. And then it carries with it as well many notices and alerts and other communications. For example, under Medicaid rules, people have to be reassessed at different intervals and what the CDM does is to send out the alert so that those things don't get lost and can be done on time. 33 Some examples -- moving on to slide 25 -- of how the CILs are already participating in Cash and Counseling and we're very lucky today to have someone here from Minnesota and Rhode Island. In Minnesota they've been doing outreach and recruitment efforts for the state. They've been doing some major enrollment efforts including calling participants, really explaining the program, and then following up. In Rhode Island, the independent living center does peer support. They are one of the fiscal employer agents in Rhode Island and they also provide the support broker role which in Rhode Island is called advisement. So at this point I'll turn it over to Vicki Dalle Molle from Minnesota who will explain to us a little bit more about what Minnesota independent living centers are doing. Vickie... >> VICKI: Thank you. This is Vicki Dalle Molle and I'm with the Minnesota Center for Independent Living, our main office is located in Rochester, Minnesota. This is one of three centers for independent living providing enrollment assistant services under contract with the state's Department of Human Services. And what we are doing, and there has been this big shift in Minnesota, a way from having services being traditionally system-focused where there are lots of rules and professionals know best and basically the consumer has very little direct control over the needed support, and moving more into a person centered philosophy across the state where the consumer is the expert, consumer has the direct control over near their resources and can plan for their service and support based on their personal preferences 34 and priorities. And so in order to further the process in Minnesota, the Department of Human Services contracted with three of the centers so that we could directly educate and help enroll persons on the elderly waiver and the alternative care waiver. Those are two uses of M. A. dollars, Medicaid dollars in the state of Minnesota and it's for folks who are 65 years of age and older. And so what we did with those populations on those two different waivers in the state is that we did a direct mail campaign and we followed up with phone calls. So we were the first point of contact for many people in our area of the state to learn about what is called in our state the consumer-directed community supports and that's what we call our Cash and Counseling project in the state of Minnesota. And what we really do is in the basic model for Cash and Counseling that Kevin went through, we really focus on step three and we work to ensure that consumers receive enough information to make an unbiased personal choice between managing their own services or receiving traditional agency delivered services. And so we will explain what consumer-directed community supports are and how they might be able to use their waiver funding in different ways to have a more personalized plan. Many people use it because the two key points -- I think our main selling points is that folks get to continue to stay at home. Couples can stay together because you can hire your spouse, and you can have services and support from people that you know and feel comfortable with. This has worked especially well in Minnesota in our rural areas. We have found 35 though in counties where it's extremely service rich this particular model is not always the choice that people make, but, you know, once again as Kevin explained. It is a choice. It's not for everyone. We just find that those who do choose it tend to be in areas not as service rich and where people especially want to hire family members. So we provide the educational sessions and go into great detail because consumers need to know about the health and safety considerations for their support plan. They need to have information about the service parameters for consumer-directed community supports. We will work with family members and we often have Ed sessions with the consumer, any family members or representative that they would like to have present and we often have representation from the lead agencies which are either county social workers or someone from a managed care plan. And so as we explain everything, we also then leave them with that information and we talk to them about what the next steps are because beyond what our role is as a Center for Independent Living, if folks choose to go forward and develop a plan, they do that with the help of a support broker, which in the state is called a flexible case manager. And then the fiscal side of it is handled by a fiscal support entity so consumers work with two other service providers in order to have their plan developed and then ultimately approved by their counties. The other thing that we do that has been very important is that we have a key advocacy role because there are times when -- I'm trying to figure out how to say this delicately -- but there is not always the support that you might expect for folks who might want this option from 36 county case managers. And so we play that advocacy role so that if a consumer really wants to pursue it, we'll work through whatever the stumbling blocks are for this particular person in having their choice to use CDCS. And then we also will do troubleshooting of various issues for DHS in our region. Each of the centers have a quarterly regional meeting and providers from all over our service area come and talk about specific things related to CDCS and how we might work through those issues so that more consumers can be enrolled. So that's been our role basically has been one really of making sure that consumers have the information they need to make an informed choice and that if they choose to go with CDCS, then we help them navigate the rest of the system in order to have their support plan developed and approved. The other thing that we do besides helping lead agencies where we can, is that we've begun to network in our regions with different aging network providers. So we have senior linkage line that has outreach service provision is part of that linkage line and we also work with area agencies on aging in our state in order to make sure that everyone who is on this waiver who might want to know about this knows about it and can make a choice as to whether they want it. And that would be it for me. >> LEE: Great, thank you, Vicki. Turning now to Rhode Island. I'm going to do the slides, but when we get to the Q. and A., we have with us today sue Bilodeau from Perry which is one of the independent living centers in Rhode Island. And Perry in Rhode Island plays a very significant role in the Cash and Counseling program there. They are one of the fiscal employer agencies. So a participant can have their payroll and 37 taxes and workers' comp and all done by Perry. They are also a support broker in Rhode Island and in Rhode Island they call that an advisement role which is really the support counselor that helps to -- helps the participant put a plan together and then helps them access services if they need more support. They provide the usual peer support array of services that independent living centers provide and they provide advocacy assistance if a participant needs help advocating to get the kind of plan he or she wants. One thing that Perry is doing that has great promise and seems to be relatively new, if you look across the country, is they are having their assessments for consumers -- participants performed by Certified Occupational Therapy Assistants called COTAs and they are finding that this particular group of people is particularly effective in helping participants really identify their needs and preferences and translating those into a plan, and at the same time they can recommend assistive technology that will promote independence. I would note that in Rhode Island the assistive technology benefit under Medicaid isn't part of the Cash and Counseling program because the participants already are entitled to that under the regular Medicaid state plan. For those of you that have more familiarity with some other models of service delivery for personal assistance, we thought we would provide just a very brief comparison of the differences. In one model is something known as agency with choice, for example, in New Hampshire the independent living center is an agency with choice. It's for personal assistance only. The agency -- the independent living center is the employer of record. 38 They provide all of the financial services, payroll, taxes, workers' comp, that kind of thing, but there is no flexible budget. It's just the personal assistance services that are a part of the program. The difference with Cash and Counseling is that in addition to the personal assistance, participants can purchase other goods and services similar to those that Kevin mentioned earlier. In Cash and Counseling, it's the individual who is the employer of record. There is though a separate fiscal employer agency, if you will, that provides the financial services and the individual in a Cash and Counseling program has a really flexible budget that can be used both for personal supports and the purchase of other goods and services. Connecticut, when they were trying to transition people out of nursing facilities and into the home and community-based programs has a program in which on a one time basis the participant, when they are getting out of the nursing facility can have access to a pot of money for something other than waiver services to make sure that they can actually transition to the community. For example, they might use it for the down payment on an apartment; but once they are in the community under their nursing home transition program, they have been limited to traditional waiver services. So what Cash and Counseling offers is kind of the pot of money on an ongoing basis as part of the individualized personal budget the individual has the flexibility to purchase items that may facilitate more independence and more security in the community. With that, I think Sharon we can have another Q. and A. and turn it back to Kevin to sum up. 39 >> SHARON: Thank you. Jade, are there any questions from the teleconference? >> OPERATOR: I'd like to remind everybody to ask a question please press star 1. >> SHARON: There are no webcast E-mail questions. >> OPERATOR: Okay, we do have one question in the cue from Geraldine. >> CALLER: My question has to do with the centers for independent living, if they were working with the Cash and Counseling are they reimbursed for any of their services that they give to assist individuals under this program? >> LEE: In Minnesota the way that that is handled is that we're working under contract with the state Department of Human Services and under that contract we are paid to provide the enrollment assistant services. We don't receive any payment from the consumers we work with, however. >> CALLER: Okay, thank you. >> LEE: And it's the same thing in Rhode Island except if the person has a copay if they go over the Medicaid limit, but then they pay a copay. >> CALLER: Okay, thank you very much. >> KEVIN: This is Kevin Mahoney at the National Program Office and I'd like to even build on that. In Minnesota -- and you know I want to compliment Vicki and the three independent living centers in Minnesota, the state -- I think at the beginning enrollment was spotty and again Minnesota 40 is a state that's very decentralized. You know, people enrolled through their counties or managed health plans and when the state was able to use some of the funding they had from Robert Wood Johnson Foundation to contract with the CILs, it really turned things around to hear about this from a trusted organization. Now, in Minnesota they were lucky because they were one of the states that had gotten grants from Robert Wood Johnson Foundation and that was one of the allowable uses of the money and it was money really well spent. When you get over to the Perry, and Susan Bilodeau who is here from Rhode Island could answer more specific questions, you know, Rhode Island right now has, if I'm right, two different organizations that offer the fiscal management service and Perry is one of them. And they have two different organizations that offer the support broker function and Perry is one of them. Fiscal management services and support brokers are really an intimate, integral part of the whole Cash and Counseling model and in every state those have really work out as services that the state, you know, contracts for and needs in order to operate a Cash and Counseling model. Susan, you haven't had a chance to say anything. Do you want to add anything about what Perry is doing? >>Susan: No, I think it's all been said finally. >> OPERATOR: Okay, we do have another question in the key from Tonia Torres. >> CALLER: Actually it's two questions. One of the two states that are reporting today, are all the centers in each one of those states 41 participating in Cash and Counseling in some way? And then secondly, are there any restrictions on CILs doing multiple functions under Cash and Counseling or can they do it all? >> VICKI: This is Vicki from Minnesota. In our state only three of the eight centers for independent living are providing enrollment assistance services through the contract with the Department of Human Services. And we do have restrictions on -- this contract was specifically for enrollment assistance and education. Any advocacy through the process, the goal was to help a consumer achieve their goal to be on consumer-directed community support option if they wished. The restriction for us was that staff at the three centers for independent living could not become a flexible case manager, and we could not be affiliated with a fiscal support entity. So a flexible case manager is the person who completes that -- works with the consumer on a community support plan and is paid by the consumer for that help. And then the fiscal support entity is the one who manages payroll and that kind of thing. So we couldn't be involved in either of those other processes while we were working on this contract. Our contract is due to expire and there are several staff from the three centers who have worked on this contract will now become flexible case managers and that's how we'll help consumers in our area with this particular option. >> KEVIN: This is Kevin Mahoney from the National Program Office. If I give -- I don't know what to say -- more of an overview. One of the reasons we were dying to have this call is our states have been of 42 varying success in involving the independent living centers in their states. Quite truthfully, we wanted in the states that have Cash and Counseling, we wanted to make sure we were doing everything we could to open up dialogue because our goals are so compatible and parallel and interdependent. So for those of you in those 15 states, you know, what I'm saying is if you go to our website and you may have already done this, so this may not be necessary, but you just click on that state and it gives you the contact information, you know, with your particular state and we're just dying to foster increased communication. Whereas for those of you that don't have Cash and Counseling, we're just wanting to make sure to the extent we could that you are aware now that under the deficit reduction act this can be done in every state without a waiver and so it's to really promote conversations within your states of couldn't this be an option in our state as well? You know, sad to say I don't -- under the Robert Wood Johnson Foundation grant states had like $250,000, you know, that they could really use to get this up and running and that may not be as possible, you know, in states that will be starting from this point on. On the other hand, why not talk to your state? Because like some of the states that have these new aging grants may also be really able to look at things afresh. >> OPERATOR: Okay. Thank you. There are no further questions in the queue. >> KEVIN: What I'd like to do is -- you know, because I see we're past our 90 minutes, and we can keep going, but I don't want to try 43 your patience. The overheads that are the next ones are really much more detailed explanation of the Cash and Counseling vision statement and the central elements and those -- you know, I might really commend to you to look at at your leisure, but it's certainly Cash and Counseling reflects that individuals if they are only given the choice will exercise choice in way that is maximize their quality of life and whereas Cash and Counseling is just one option we feel it should be open to everyone and because it's voluntary we also believe people should have the ability to return to the traditional system at any time. But you can look at these more at your leisure and then what we've put in are what are the key elements as far as state responsibilities and what are the key elements as far as the support -- the system of supports, the support broker and the fiscal management services, different states may find these duties to different entities and do it in different ways, but these are, we believe, sort of the key elements that better be there to have a successful program. And so I would really want to go all the way to the last slide, No. 45, as the one that you keep in your mind because all of this information can be accessed by you from this day on. You see our website at cashandcounselling.org. And you see contact information for Erin McGaffigan and Lee Bezanson. I'm not disappointed opinion your questions were so good earlier in this that it really drew out many of these elements of the vision and responsibilities and among the parts that I'm glad we really did have a chance to talk about is how can independent living centers play a role like in Minnesota or like in Rhode Island and how can 44 we work together to make this an option everywhere? So you at ILRU can guide me, if there is any time I would use it for questions, but we've greatly appreciated the chance to meet with you today. >> SHARON: Thank you, Kevin. Can we touch base one last time, Jade, with the teleconference and see if there is any callers that have questions? >> OPERATOR: Yes, ma'am. If you'd like to ask a question, press star 1 at this time. >> SHARON: Thank you. >> OPERATOR: Okay, there is one last question from Karen. >> CALLER: Hi, if a consumer wanted -- I live in California and I understand we don't have the Cash and Counseling program up and running, but I know we have -- we're supposed to all be in compliance with Olmstead and try and have a plan and I've been seeing some things popping up on the state website is health and human services and I think there is basically like maybe some pilot programs and projects and I'm just wondering as a consumer how can -- who are they to talk to to get the services to live in a community-based setting rather than be forced to continue to live in an institution? Who would they talk to? >> KEVIN: Well, I'll take a stab, but as I say, Cash and Counseling isn't one of the states that we've worked closely with on Cash and Counseling. So I'm doing this from my -- I actually worked for the state of California for a number of years. So I'm drawing on my old knowledge. California has that in-home supportive services program, that IHHS 45 program that basically I believe is accessed at the county level and to my knowledge has over 300,000 consumers on it right now, participants on it. 80 or 90 percent of whom can at least choose their own worker. So I mean as far as accessing -- and then of course the state has the MSSP program which is a more intensive range of services, but as far as if someone is really interested in how can we go this next step and do a Cash and Counseling model, you know, and how do I try and spark interest in my own state. On our website you can just download a very brief brochure that captures these research results, testimonials from participants who really had their lives changed and from governors and key state officials and legislators, also by contacting one of us. We've been trying to put together a packet that would at least get people started so they could talk to their state Medicaid directors about how do we get this option in our state. >> SHARON: Thank you, Kevin. Thank you all. Really useful information on Cash and Counseling that I know the centers and others will be using in the future. I'd like to thank those responsible for today's presentation, our sponsor, the Cash and Counseling National Program Office at Boston College. The webcast team, Dr. John Searle for his technical expertise, and our captioner, Marie Bryant. The opinions and views expressed todays are those of the presenters and no endorsement of the sponsoring agency should be inferred. Thank you all for joining us today. We will be archiving all of the material, including the PowerPoint and the audio and text transcript from 46 today's presentation. So feel free to share this with your colleagues who weren't able to join us today. Again, thank you for joining us and have a good afternoon.