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DOORS: Individual Budgets DOORS: Individual Budgets Based on Individual NeedsBased on Individual Needs
Jon Fortune, EdDJon Fortune, EdD
Wyoming Department of HealthWyoming Department of HealthDevelopmental Disabilities DivisionDevelopmental Disabilities Division
IASSID World Conference
Montpellier, France
June 15, 2004
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The
ETERNAL QUESTION:
How do we deliver what we have
to the people who need it most ?
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Before
Unexplained48%ICAP
37%
Services9%
Geographic1%
Provider5%
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After (2003 Adults)
Client Char.48%
Services20%
Unexplained25%
Day2%
Residential5%
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Introduction
DOORS Model Stepwise regression Individual budget for each person
served for use by the local team Uses regular Medicaid HCBS DD waiver Funding related to characteristics of
person Wyoming financial architecture
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Overview - History & Results Began in July 1998 for adults and in
January 1999 for children No hearings to date Some requests for State Level of Care
Review Focus on the needs of the person
served Very stable for financial planning
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Agenda What did we tell the families and people
served? Campbell & Heal, 1995 AJMR Rhoades & Altman, 2001 MR ICAP items and other data pieces DOORS - Gary Smith & Bob Clabby Model can be done on a spreadsheet
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N e w W y o m i n g P e o p l e S e r v e d & W a i t i n g f o r W a i v e r S e r v i c e s
0200400600800
100012001400160018002000
W aitin gS erved
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Model - “A tentative description of a system or theory that accounts for all of its known properties.” (American
Heritage Dictionary, 1985) - we are referring to a mathematical formula which attempts to describe the relationship between independent predictors and dependent measures of interest like the budget for reimbursement
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Assumptions:
1. Individual People have needs, not providers, agencies, or groups.
2. Individuals with greater needs should have access to more resources; those with lesser needs should get less.
3. No two people have the same needs, supports and priorities. The word “Individual” must mean something.
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Assumptions: (cont.)
4. Individuals and their teams know best what services are most important for that person, not the State.
5. People should choose providers, not the other way around.
6. It is possible to make it happen.
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Overview - StrategyFairness, equitability, explicabilityMatch resources and individual needsAbility to handle special
cases In a time of limited resources - focus
on those with greatest demonstrated need
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Overview - Strategy Find predictors that we can
use for constructing a statistical model, or formula, to generate predicted budget for each eligible person on the waiver
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What factors explain variance? (Remember, your results at home should vary!)
Autism, Deafness, Mental Illness, level of MR, health limitations, psychotropic meds, lives with family, ICAP Broad Independence, ICAP Gen Maladaptive, lives independently, SE, etc.
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RobustnessThe techniques are often powerful enough to be able to overcome minor error and work well
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All the predictors work together as a team, like the attacking army on a chessboard
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Column A Column B Column C Column D Column E
Parameter Variable Estimated
Predictor Variable Estimate Value B x C Range
Base Amount (Intercept) 4.39005 1 4.39005
ICAP Measures
ICAP Broad Independence -0.00279495 404 -1.1291598 $7,487
ICAP General Maladaptive -0.004806757 -12 0.057681084 $1,887
Age -0.002205103 32 -0.070563296 $1,124
Dx: Autism? 0.088635 0 0 $881
Dx: Brain/Neurological Damage? 0.045409 0 0 $425
Dx: Chemical Dependency? 0.11922 0 0 $1,230
Dx: Deafness? 0.12074 0 0 $1,248
Level of Mental Retardation 0.030344 3 0.091032 $1,131
Psychotropic Medications? 0.071711 0 0 $653
Lives with Family? -0.14618 0 0 $1,200
Lives Independently? -0.25273 0 0 $1,757
Independent with Monitoring? -0.078247 0 0 $663
Sheltered Workshop? -0.056035 0 0 $489
Supported Employment? -0.092672 0 0 $779
Competitive Employment? -0.14002 0 0 $1,107
Home & Community-Based Services
Residential Services? 0.24897 1 0.24897 $1,926
Day Habilitation? 0.10444 1 0.10444 $878
Nursing? 0.10268 0 0 $943
Personal Care? 0.1309 0 0 $1,420
Psychological Services? 0.083741 1 0.083741 $800
Second Assessment? 0.03118 0 0 $284
In-home Services? 0.066377 0 0 $637
Sum: Predicted Log10 Monthly Rate 3.776190988
Predicted Monthly Rate (10 to the power) $5,972.98
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Database Invaluable
Information about people served and service use is needed
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Regression - Comments, Conditions & Caveats: It is best to have “orthogonal” regressors;
ones not correlated with each other, not collinear
An important regressor might have a large probability value (i.e. may not be statistically significant) if the sample is small, if the regressor measures a narrow range with large measurement errors, or a closely related regressor is included
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LimitationsThere are someHold some dollars for
exceptional casesThere is a budgetThis surprises no one
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Does not ensure enough money Can provide a fair way to distribute the
money available Does offer a way for money to follow
the person served Provides the local team an
understandable budget that they can use in pursuit of choices & preferences
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Wyoming Financial Architecture
1. DOORS to match dollars to people
2. Clear assignment of authority to make decisions about services to local team that supports each person
3. Authority for individuals to select their own service coordinators
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Wyoming Financial Architecture
4. Resolute adherence to principle that individuals and families have free choice of service providers
5. Policies that encourage – rather than impede – new providers stepping forward to offer supports to individuals
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The Four “P”s
1. PERSONAL* Individual, not group* Real information about each person* Model comes from individual characteristics,
not the other way
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The Four “P”s
2. PORTABLE * Person has funding, not
provider * Person chooses provider * Funding moves with the
person * No “guaranteed clients”
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The Four “P”s
3. PRIORITIZED
* Person & Team set priorities
* People with greatest need get most
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The Four “P”s
4. PREDICTABLE
Both the Individual and System know & plan within their limits
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Special Thanks toProfessor Laird Heal
Bradley K. Hill (ICAP)
Wayne Johnson
Edward M. Campbell, Ph.D.
Don Severance
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“DOORS” Contact Information
Jon Fortune, Ed.D.
DDD Wyoming Web Site
http://ddd.state.wy.us