Recommendations on Rebalancing Long Term Care

BACKGROUND INFORMATION

Rebalancing Long-term Care in Illinois is a broad effort by the State to provide opportunity for persons with disabilities and seniors to choose to live in appropriate, permanent, integrated settings in the community; moving out of institutional settings. Rebalancing long-term care links a number of initiatives and has profound impact on the long standing infrastructure serving the elderly and persons with disabilities. Rebalancing Long-term Care also addresses adjustment to the allocation and investment of resources from institutional to community-based care. These Rebalancing Initiatives have been driven by a combination of federal incentive programs, legal mandates based on Olmsteadⁱ consent decrees, long standing advocacy and best practice outcomes for persons with disabilities and the elderly, and realization of potential savings through closure of costly state facilities. Uniformly, implementation of Rebalancing efforts is based on core principles of choice, maximum independence in a safe environment, and quality community based services for individuals. In all instances, a successful transition will include housing and services that meet an individualized plan.

Rebalancing Initiatives Summary Impact Chart (additional detail provided in Appendix I)

Initiative	Population Impacted	Facility Impacted	Geography	Est. Population	Timeline	State Agency
Money Follows the Person	MI, PhysD, DD, elderly	Skilled nursing facilities for >90 days	Statewide	Est. 3500 transitions	By 2016	HFS; IDoA and IDHS
Williams	MI	Institutes of Mental Disease (IMD)	Chicago metro, Decatur, Kankakee, Peoria	Est. pop. 4500	5 yrs.	IDHS/DMH
Colbert	MI, PhysD, elderly	Skilled nursing facilities	Cook County	Est. pop. 16,000-20,000; 1100 transition in 3 yrs	3 yrs. - cost neutral assessment	HFS; IDoA and IDHS
Ligas	DD	Intermediate Care Facilities/DD	Statewide	100% of persons in institutional care requesting transition and 3,000 in need of services in family homes (total unserved in the community is greater)	6 yrs.	IDHS/DD
State Closures	DD/MI	SODC/SOPH	Targeted locations	TBD	TBD	Gov. Office; IDHS/DD and DMH

HUMAN SERVICES COMMISSION REBALANCING WORKGROUP

The Illinois Human Service Commission (HSC) was charged in December 2011, by Governor Quinn to identify strategies that "significantly expand community options" for individuals with special needs to live in community settings. The primary agenda set by the HSC Rebalancing Workgroup was to focus on recommendations

to enhance and build community capacity for housing and services to meet the needs of individuals moving from institutions,
to identify and align available resources to support Rebalancing for Long-term Care, and
to coordinate for positive impact on Rebalancing the managed care, Medicaid and healthcare reform efforts. The HSC Rebalancing Workgroup discussions included representatives from a large constituency of stakeholders including community service and housing providers, individual and family advocates, state agency personnel, and invested philanthropic partners. Significant discussion within the Workgroup centered on definitions and choice of living options. In the end the range of housing settings may vary, are based on choice of the individual, and are defined by the characteristics that decrease segregation of persons with disabilities, and increase options and supports that advance independence, privacy, and control over daily living for individuals.

All recommendations from the HSC Rebalancing Workgroup reflect the "core principles" identified in the Workgroup discussions:

Choice of living options - Offer and support a range of permanent housing from independent apartments to more structured or congregate settings that promote independence and community, respond to service needs, maximize the individual's abilities, and honor the individual's preferences, including those who choose to live in institutional settings. Maintain communication with individuals, families, and guardians to assure full understanding and informed choices regarding living options and community services.

Communication and transparency - Clear communication of policies, choices, resources, and outcomes (favorable and unfavorable) will help to inform and build a stronger Long-term Care System.

Quality of services and settings - Assure quality of available services and settings through investment in a coordinated and capable network of providers, supports, and infrastructure.

Maximize and align resources - Identify and understand the full potential of resources and design efficient and effective systems for service delivery.

The HSC Rebalancing Workgroup through its discussions recognized both the opportunities and challenges involved with Rebalancing Long-term Care in Illinois:

Opportunities:

Implement meaningful system change in the quality of life and independence for persons with disabilities and elderly formerly living in institutions
Improved transition, support, and service delivery through training and best practice studies
Improved outcomes for individuals through coordinated case management and service delivery

Increased access to Federal resources to leverage the State's financial investment in housing and services for persons with disabilities
Broaden Rebalancing system changes to strengthen community care prior to moving to institutions, develop and implement individual service plans to reduce the length of stay in institutions; thereby reducing the number of individuals entering and remaining in institutional care unnecessarily
Achieve and redistribute cost savings through reduced investment in institutional care towards enhanced housing and service capacity in community

Challenges:

Expectations for large number of people to be transitioned over a fairly short period of time
Complexity of needs of individuals, including varied needs between and within the targeted groups - elderly, physical disabilities, DD and MI - multiple diagnoses and complicated health issues
The current Medicaid waiver eligibility and service delivery system is structured in "silos" based on demographics and diagnoses rather than on a coordinated system that addresses the individual's multiple needs.
Limitations in the availability of affordable community-based housing
General concerns that the quality and availability of care in the community will be diminished
Need to build supports, life and socialization skills for individuals leaving institutional care to become more adept to manage responsibilities of independent living
The current fiscal crisis in the State has resulted in reduced funding for community services and limited resources available to increase and enhance service delivery in the community
Recent cuts to eligibility and coverage limits under Medicaid, enacted to stabilize the long term viability of the State's Program, could impact availability of services for the individuals relocating under the Rebalancing Initiatives and raise the risk of increased institutional care

The closure of State operated facilities brings about additional challenges:

Many residents in developmental centers have lived most of their lives in similar care facilities and require significant support and skills enhancement as they transition into community living
Potential job loss and retraining for State employees at closed facilities, and the potential negative impact on economic conditions in local communities
Closure of psychiatric hospitals removes a significant component of the crisis care network for persons with mental illness

RECOMMENDATIONS

Coinciding with the work of the HSC Rebalancing Workgroup, numerous other workgroups and advisory committeesⁱⁱ including State agencies, community providers, advocates, residents and families were actively engaged and generating implementation plans and recommendations on Rebalancing Long-term Care in Illinois. The HSC Rebalancing Recommendations are informed by the reports and discussions of these other workgroups. Detailed issues and actions reported from these workgroups are compiled in a series of charts in the Appendix to this report. The Appendices I and II are provided for informational purposes and not included as part of the Recommendations presented and approved by the IL Human Service Commission.

The HSC Rebalancing Recommendations call for and address the need for increased coordination of planning, implementation and reporting of the Rebalancing efforts.

Build a Broader Civic and Community Consensus In Support of Rebalancing Long-term Care

Recommendation 1: Develop a communication and public information campaign to build a broader community consensus on the importance of Rebalancing Long-term Care for Illinois.

The Rebalancing of Long-term Care for Illinois is a large scale effort, the success of which is based on the involvement of stakeholders at all levels of decision making. This effort encompasses numerous State and government agencies, persons with disabilities, families, guardians, advocates, leadership and staff from a broad range of community service and healthcare providers, the philanthropic community, legislators as well as new partners including, managed care companies, and private and public housing providers. Robust, current communication tools are necessary to fully inform, engage and maximize participation from a broad group of constituents, stakeholders, and the general community.

Develop "education and engagement forums" designed to bring Rebalancing concepts, plans, goals, and achievements to targeted audiences to expand understanding and build broader community constituency and support. Specific attention should be paid to building local municipal and business community support for housing developments, zoning, funding, community and natural support networks, and employment strategies that need community and political support, without which meeting the Rebalancing goals may not be met.
Build out electronic communication tools (websites, online applications, surveys, and social media) to disseminate information, gather input, and engage in dialogue that will keep stakeholders and the general public informed on issues impacting Rebalancing.
Institute broad information dissemination on current and ongoing Rebalancing outcomes to foster greater understanding and trust among stakeholders and enable learning and improvements from early experiences.

Comprehensive Implementation Planning for Rebalancing Long-term Care

Recommendation 2: Compile a Comprehensive Rebalancing Strategic Workplan incorporating individual plans, transition goals and outcomes, strategies, financial resources, and timelines.

Currently not less than five implementation plans have been developed by State agencies and partners to meet the Rebalancing goals in Illinois. While individual plans are necessitated by court mandates and programmatic requirements, all stakeholders would benefit from a Comprehensive Rebalancing Strategic Workplan that brings together into one document the core components of the various plans. A "crosswalk" plan would highlight strategies to address key overlapping components between and among the Plans, ascertain increased funding needs, and identify conflicts or strains on the systems resulting from roll-out of plans simultaneously. At the same time a comprehensive plan should not diminish the specific programs, activities and accountability designed to serve the discrete populations.

Build a Comprehensive Rebalancing Strategic Workplan to highlight strategies that address the overlapping demands on the systems: building service provider infrastructure and capacity; transition planning and implementation; housing development strategies; and coordination of Rebalancing and managed care implementation. Key partners and accountable entities responsible for implementation should be identified along with respective timeframes.
Create a Rebalancing Financial Plan that identifies the current and projected resources allocated for Rebalancing within the State Budget by Department and Division, federal, and private and philanthropic resources. The Rebalancing Financial Plan will set the foundation to identify funding gaps and new resources essential for successful implementation. The Rebalancing Financial Plan should establish system goals such as proportion of Medicaid resources expended for community care, reporting on Section 811 and other federal resources, and create a mechanism to track cost off-sets and savings between programs/agencies that result from moving individuals from institutional care to community-based services. (Potential Model: IDoA Community Supportive Services FY-13 Budget Presentation and Rebalancing report detail required under PA 96-1501 Medicaid Reform Law.)
Ensure input, coordination and accountability across Rebalancing Initiatives through expansion of the current Interagency Long-term Care Group or creation of other agency and stakeholder oversight body.

Delivery of Services in the Community

Recommendation 3: Develop a plan to build community capacity and service delivery that outlines strategies to meet service and support needs of individuals with disabilities living in the community.

People with disabilities are able to live a quality life in the community when sufficient supports and coordination of care is available. Illinois has the benefit of a long standing and experienced community provider network. However despite this provider expertise, concerns exist about the current capacity (depth of service, geographic location, multiple diagnosis expertise, and availability of crisis care) of the network to meet the complex and comprehensive needs of the large number of individuals with disabilities moving under Rebalancing. Successful Rebalancing efforts rest on building the short and long-term capacity of these service providers in all areas of the State and identifying the resources and flexible payment mechanisms to deliver increased and multiple services in smaller settings in the community.

Conduct a comprehensive survey of service capacity of providers across disabilities that identify common services delivered, staffing levels and credentials, and funding sources needed. The survey would also capture geographic coverage and unique services.
Expand service delivery models, training curriculum and peer-to-peer networks that provide inter-disciplinary and cross-disability service, and enable maximum independence for individuals with disabilities.
Develop and finance professional development, career ladder and earning opportunities for existing provider staff and longstanding staff of institutional settings transitioning their skills to community providers.
Design and implement adequate reimbursement rates and flexible payment structures for complex service delivery in smaller community setting.

Building the Community-Based Housing Infrastructure

Recommendation 4: Develop a strategic plan to clearly identify the housing needs and goals, the resource allocations, the accomplishments to date and gaps in the systems, and the strategies to fill the gaps across the Rebalancing Initiatives.

The State of Illinois has allocated capital resources for private and nonprofit developers to acquire, rehabilitate and construct community based housing for persons with disabilities moving from nursing facilities and intermediate care facilities. Partnerships are being formed with local and state governments and with public housing authorities to leverage additional units and rent subsidies. These strong efforts must continue and would benefit from a roadmap plan that can direct efforts and track achievements in meeting both the unit and affordability needs.

Identify target production goals for type of units with emphasis on non-segregated or four person or less homes, high demand geographic locations, physical accessibility, ownership/management structure, and realistic timelines.
Build on comprehensive outreach and training for landlords, owner associations, community partners to foster understanding of Rebalancing goals, resources and service supports, and opportunities for partnership to expand existing private and public housing stock available for Rebalancing initiatives.
Develop financial models that can leverage private and public resources for development of community based housing; reconfigure payment structure to enable increased development of small group homes; and maximize opportunities for rental assistance to increase affordability.
Strengthen notification and referral system for units set-aside and/or accessible for persons with disabilities, and those relocating under the Rebalancing efforts.

Maximize Medicaid Flexibility

Recommendation 5: The State and stakeholders should conduct, and report on, an analysis to determine benefits, costs and impact on Rebalancing of adopting and implementing enhancements to expand coverage and streamline payment processes under the existing and new home and community based service options for individuals transitioning under eligible Rebalancing Initiatives.

The Medicaid Program funded by the State and supported by federal match is a primary resource allocated to fund services and supports for Rebalancing Long-term Care in Illinois. Through the years (most recently in the Protection and Affordable Care Act of 2010, ACA) the federal Medicaid Program has implemented changes and advanced opportunities - through state plan options, waivers and incentive programs - for states to build flexibility enabling people with disabilities to receive long-term care services and supports in their homes and in a range of community residential care settings. Notwithstanding adoption of state plan options or waivers in Illinois, the Medicaid service taxonomy remains fragmented and inefficient for people with multiple disabilities and the providers that serve them. The SMART Act (PA 097-0689) passed by the Illinois legislature in 2012 states that its goal is to make changes to Medicaid in order stabilize the program for the future. Concerns have been raised about service coverage for persons in the community dependent on Medicaid support.

Identify opportunities to increase flexibility and coverage across disabilities and streamline provider billing processes across State Plan options and existing HCBS waivers. Determine whether the new long-term service and support options under ACA provide greater opportunities and resources for Rebalancing. Understand the offsetting detriments or costs associated with implementing these changes.
Focus on the implications on Rebalancing of the Smart Act Medicaid program changes, with specific look at DON score thresholds and assessments, and service limits or reductions.
Design and implement flexible payment structures for service delivery that maximize resources and blend service delivery based on the changes underway for Medicaid and managed care.

Coordinating Managed Care with Rebalancing

Recommendation 6: State agency, managed care entities, and providers as identified by the State of Illinois must coordinate implementation of managed care to clearly demonstrate the roles and responsibilities, service components for individual coverage, and opportunities for improved outcomes created under coordinated care.

Rebalancing resources and services are managed by a variety of State agencies and community service providers based on specialty or disability expertise, resource requirements and historical structure. This "silo" infrastructure provides the benefits of specialized expertise and diverse philosophies of support, but also creates barriers to efficient and comprehensive service delivery for individuals transitioning under Rebalancing. The State is taking steps to break down these barriers through the implementation of integrated coordinated care.

The 2011 Illinois Medicaid Reform legislation (PA-96-1501) requires that by January 2015 at least 50% of all Medicaid clients be enrolled in a coordinated system of care and that payment systems for coordinated care be revised to disburse on performance based outcomes. With Medicaid as a primary resource supporting Rebalancing, the State's planned roll-out to a multi-phased coordinated care system intersects directly with Rebalancing efforts, requiring strong leadership, open communication, and investment in a broad range of community transition and support training and education for all participants. The State can utilize coordinated care initiatives, existing peer support systems, and Rebalancing to identify opportunities and training for providers to deliver a range of services for a single client or resident across disabilities, programs, and funding sources.

Create a detailed timeline of the roll-out of the multi-phased care coordination and how it aligns with each Rebalancing initiative. This timeline will also list the service/care options available to transitioning individuals at each phase of implementation along with the requirements for community providers to engage (operationally, fiscally, reporting) with the entities accountable for the health care network(s).
Develop a "mutual education curriculum" to foster understanding and partnerships between managed care and community services and housing providers. This curriculum will cover eligibility requirements, enrollment processes, care coordination, and other case management services for individuals under Rebalancing.
Maximize the opportunity available under the Illinois Care Coordination Innovations Project, and the new Coordinated Care Entities and Managed Care Community Networks to demonstrate and advance coordinated care for persons with disabilities transitioning to community settings from institutional care.
Fully implement the unified budget mechanism that enables the transfer of funding for services between agencies to follow the resource needs of individuals transitioned from nursing facilities to community living.

The Appendices I and II are provided for informational purposes and are not included as part of the Recommendations presented and approved by the Illinois Human Services Commission.

Appendix I - Additional Background Information on Rebalancing Initiatives

Money Follows the Person (MFP) - Money Follows the Person is a federal program providing financial incentive through enhanced Medicaid match to move from institutional care to community care models. The enhanced match is available from the federal government for 12 months following transition to community based living. Many of the costs associated with the transition of residents are eligible for reimbursement under Medicaid and the enhanced match. Transitions from other Rebalancing Initiatives will often overlap with MFP.

Olmstead Court Decrees - In 1999, the Supreme Court ruled under the Olmstead Decision that States had an obligation to provide reasonable choice for community living for persons with disabilities and elderly confined in nursing homes or other institutions. Since the Olmstead Decision, Illinois has settled three lawsuits (differentiated by the population and type of facility) which mandate the State move forward with diligence to provide opportunity for community living and services for class members.

Williams - The Williams Consent Decree includes an estimated 4500 persons with mental illness living in Institutes of Mental Disease (IMDs). Geographically the IMDs in Illinois are concentrated in the Chicago metropolitan area; with additional locations in Decatur, Peoria, and Kankakee. The Williams Consent Decree and Implementation Plan approved by the Court calls for full implementation over a five year period beginning in July 2011.

Ligas - The Ligas Consent Decree mandates the State of Illinois provide opportunity to move and receive services in community settings for 100% of persons with developmental disabilities living in Intermediate Care Facilities for persons with Developmental Disabilities (ICF/DD) statewide that choose to move; and for new service provision for an estimated 3,000 individuals living in family homes. The total population in the family homes awaiting services is significantly greater. The time frame for implementation of the Ligas Decree is six years. All Class Members still living in family homes after six years who are seeking community services shall move off the waiting list at a "reasonable pace" to received community services.

Colbert - The Colbert Consent Decree requires the State of Illinois to provide opportunity for residents in skilled nursing facilities in Cook County to move to community-based living. Colbert class members include people who have mental illness, physical disabilities, and elderly. Approximately 16,000-17,000 residents could be impacted by the Colbert Consent Decree. Recognizing the magnitude of this effort, the Colbert Decree sets a timeframe of 30 months for the State to complete initial transitions of 1100 individuals. Based upon that experience, the parties will develop a "cost neutral" assessment and plan to move the remainder of the class members who wish to move to the community while limiting the State's spending to no more in aggregate than it is spending for their care in nursing facilities.

State Facility Closures - In January 2012, Governor Pat Quinn announced plans to begin closure of certain State operated developmental centers (SODC) and psychiatric hospitals (SOPH). The plan seeks to enhance the quality of life of residents in the same vein as the Olmstead principles, but also to achieve costs savings through the closure of antiquated facilities. At least four facilities were identified for closure initially including Jacksonville Developmental Center in west central IL, Tinley Park Psychiatric Hospital in metro Chicago, Murray Developmental Center in southwest IL, and Singer Center in the Rockford area.

Appendix II - Detailed Issues and Actions from Various Rebalancing Workgroups and Reports

The following four charts incorporate many of the issues and recommended actions identified by various rebalancing and system change reports and workgroups. These charts provide a foundation for continued discussion by the HSC Rebalancing Workgroup:

Transition Process

Multi-step process to successfully transition residents to community based settings and services: Outreach, Assessment, Transition Planning and Implementation, Care Management and Monitoring.

The University of Illinois at Chicago School of Nursing Institute for Health Care Innovation recently released a report on the enrollment of 709, and transition of over 475 individuals under MFP for the period 2009-2011; specifically looking at those individuals that transitioned early, have remained in the community for over one year, or have experienced critical incidents. The central recommendations from the Report and from subsequent discussions focused on opportunities to:

Transition Issue	Actions
Increase enrollment in MFP and other Rebalancing Initiatives	Broader referral networks, improved coordination with nursing home providers, follow-up contact with residents who initially decline consideration Clear and repeated communication of information for individuals (and their family or guardians) regarding choices to assure informed and authorized decisions Build and expand current coordination through the Aging and Disability Resource Centers, and other community representatives
Enhanced training for Transition Coordinators	Assessment skills, behavioral indicators, Medicaid/Medicare services and providers, resources in the community Delineation of the responsibilities of the transition coordinators from the responsibilities more appropriately assigned to healthcare providers
Complex medical needs and dual diagnoses	Create integrated care management and broaden skills of the staffing teams
Improve transition sustainability	Identify resident specific risk mitigation needs in the service plan with specific follow-up protocol. Increase follow-up and monitoring of transitioned individuals while maintaining values of choice and self-determination
Improve Participant Self-management	Provide training for individuals pre and post transition on medicine management, life skills, service providers and 24 hr. back-up plan Deploy resources for skill development and supports for individuals both in nursing facilities (pre-transition) and in the community

Community-Based Housing

The type of independent permanent housing deemed appropriate for an individual is based on a number of factors including: the choice of the individual, the desired geography, the degree of care or services needed by the individual to maintain independent living, and the affordability of the housing. In general community-based settings can range from scattered site apartments and homes, to site-based supportive housing, to small residential supervised settings depending on the needs and desires of the individual. Certain mandated restrictions related to concentration of the targeted populations in a type of housing deemed sufficiently independent or non-institutional are outlined in the Rebalancing Initiatives.

Housing Issue	Action	Action
Minimize concentrations of persons with disabilities in single properties	Incentivize unit set asides within affordable housing developments Maximize site-based supportive housing that maintains rights of tenancy and independence with supports	Expand master lease models to scattered site units
Increase affordability for residents on limited SSI/SSDI income (<$700month)	Opportunities for rent subsidies: Section 811 program, Rental Housing Support, DMH Bridge subsidy, HOME funds, and partnerships with public housing authorities for vouchers and project based vouchers	Use capital and operating resources to write-down unit rent to 15% AMI ($8,000)
Economic stability for CILA homes at 4 beds or less	Adjust pay rate and payment timing to improve operational economics for 4 bed CILAs
Identify units in market place	Increase capability of ILhousingsearch.org: secure case manager page; mandatory listings for subsidized housing; marketing and outreach to property owners Identify vacant units in bank owned foreclosed properties, existing affordable developments and public housing inventory Target unit identification in high demand areas and build service network in areas with housing availability	Expand IFF/Access Living model of long-term property ownership for persons with disabilities Foster relationship between property management and service provider: workshop on service packages, good neighbor practices, and crisis management Explore technology supports to advance independent living Provide funding support for transition coordinators to locate housing
Quality of housing stock	Streamline inspection process and provide training for property owners	Partner with local CD programs to identify rehabilitated homes
Need for new unit creation through construction or rehabilitation	Develop RFP that "braids" resources for housing development and set-asides	Identify high need areas for new development
At-risk populations require higher level of monitoring	Incorporate skilled mental health and medical staff to on-site teams	Develop specialized housing and supervised monitoring for high risk individuals
Alternative housing models that promote independence for residents	Scattered site rental by experienced service providers Independent roommate homes with available services	Joint tenancy ownership of group homes by families of persons with disabilities

Delivery of Services in the Community

Significant concerns have been raised about the capacity of the network of community agencies to meet the complex and comprehensive needs of residents transitioned under Rebalancing.

Service Issues	Actions	Actions
Improve communication and information sharing	Launch comprehensive outreach campaign for residents, family, providers and community using media, technology and in-person methods Coordinate outreach within facilities to minimize confusion caused my multiple contacts	Improve transfer information gained in assessment and transition to service providers Create peer-to-peer education and networks for providers, residents and families
Complex health and service needs for individuals transitioning will require efficiencies in service delivery	Implement comprehensive service models - higher level including: Psych, med admin, case mgmt, crisis intervention, risk mitigation, behavioral analysis Develop levels of supervised monitoring for complex and high risk individuals	Implement a Technical Assistance Center for providers and transition coordinators to learn best practices and foster innovation Explore technology supports to advance independence
Community capacity is deficient in specific skills and geographic availability to service transitioning populations	Conduct and document a comprehensive survey of service capacity across the disability and service community Workforce training and career development to redeploy employees from state facility closures	Develop training modules for service delivery deficiencies including dental care, crisis networks. Utilize institutional care as part of short-term safety net, with specific individual plans to return the individual to the community Identify gaps in geography and target training for providers
Dual role of housing provider and service provider	Develop a "curriculum for change" training for CILA providers to facilitate the service choice for residents Separate housing funding from service funding to create greater choice for residents	Support demonstration program for group homes held by unrelated third party; with focus on quality care
Improve transition sustainability	Improve monitoring and tracking of outcomes Develop models to assess and implement service change needs for residents over time Expand service package to include social and employment services	Allow for movement to alternate housing settings to accommodate changing needs and relationships Simplify "transition fund" procedures

Financial Resources

Rebalancing Long-term Care is not only about moving people from institutional to community settings, but it requires significant redirecting and new resources to support the movement to community. The State of Illinois' current fiscal crisis places enormous pressures on the Rebalancing efforts. Simultaneously the movements to managed and coordinated care create opportunities to more effectively address the comprehensive needs of persons with disabilities living in the community.

Resource Issues	Action	Action
FY 13 Budget constraints on community based service delivery	Identify all line items across state agencies that support rebalancing	Permit bundling or other payment coordination of services across budget line items
Smart Act spending reductions in Medicaid may impact coverage for residents transitioning under Rebalancing	Implement Cook County Medicaid waiver Expand HCBS waivers to enhance coverage for rebalancing residents	Begin Medicaid qualifications as soon as eligible for residents transitioned under Williams Examine waiver of Medicaid spend-down requirements for individuals transitioning under Rebalancing
Billing systems for individual services are complex	Restructure rates as single day or bundled pay rates vs. individual service rates Coordinate Medicaid claiming systems between and among state agencies and qualified community providers	Use Coordinated Care Innovations Project models to demonstrate efficient payment across multiple service needs and providers Implement system for federal funds match to be invested in programs that support Rebalancing
Delayed payment to community providers	Identify strategies to resolve payment delays including advances and priority payments
Move 50% of eligible Medicaid recipients to Managed and Coordinated Care by 2015	Incorporate Rebalancing individuals in Coordinated Care Innovations Projects	Outreach to Managed Care agencies to develop plans for Rebalancing individuals
Identify resources post 12 month enhanced federal match under MFP.	Investigate "Critical time intervention" (CTI) model developed by Housing Solutions to reduce service needs after initial transition
Rebalancing service taxonomy includes components eligible, but not currently covered by Medicaid	Implement billing process and if necessary Medicaid waiver to cover employment services, supportive housing case management, training, and other related expenses

ⁱ Olmstead v. L.C., 527 U.S. 581 (1999) is a U.S. Supreme Court decision in which the Court ruled that States were obligated to provide opportunities for persons with disabilities who choose to live in integrated and least restrictive community-based settings.

ⁱⁱ Contributing Workgroups and Reports: Williams Consent Decree Housing Focus Forum, IL Medicaid Advisory Long Term Care Subgroup, MFP Stakeholders Group, Facility Closure Legislative Workgroup, Care Coordination Stakeholders Group, Coleman Foundation Alternative Housing Group, Pierce Family Foundation Housing Group, Williams Court Monitor Interim Report to the Court, July 25, 2012, UIC College of Nursing Institute for Health Care Innovation MFP 2009-2011 Year End Report, CSH-HDA-SHPA, Role of PSH in Implementing ACA and Medicaid Reform in IL; NAMI-IL and SHPA, IL State-Operated Facility Closure: Serving Dual Diagnoses of MI and DD, and others.