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hello and welcome to a presentation on.self-direction sponsored by the Nebraska.Department of Health and Human Services.Division of developmental disabilities.self-direction empowers people with.disabilities and their families to.design and manage services based on.their individual needs and goals.self-direction supports the essence of.community inclusion and because the.person-centered plan is individually.created by the participant and those the.participant chooses to help each plan is.as unique as the participant who.designed it.participants control their own.individualized budgets and hire and.manage their own staff supports.person-centered plans and budgets allow.participants to access the supports.needed to live at home pursue.interesting meaningful employment.volunteer or other community activities.engage in satisfying productive.relationships with family friends and.community members and maintain a healthy.lifestyle the agenda for this.presentation is to give the viewer a.brief overview of self-direction.in Nebraska we'll start with how the.self-directed model differs from the.traditional service model provide a.brief history of self-direction.describe the elements of self-direction.offer a few tools for managing.self-direction and discussed the waiver.services available in Nebraska that are.yours to self-direct we will then close.with a few final thoughts well now take.a look at how the self-directed model.differs from the traditional service.model person-centered planning is a way.of organizing around one person to.define and create a better future.thousands of people and families in.Nebraska have used person Center.planning to help them make decisions and.changes in their lives.typically in person-centered planning.the participant invites people who know.and like them to come to a meeting the.service coordinator guides and records.the discussion and decisions after the.meeting people.what's been agreed this hardly sounds.revolutionary but the frame of the.meeting the questions the meeting asks.and the way the meeting is organized.often mean new possibilities emerge new.understandings develop new alliances are.formed and people's lives take a.definite turn for the better.strong person-centered planning is.foundational to strong self-directed.service delivery self-direction is a.means by which participants are.empowered to gain control over the.selection of services and supports that.meet their own unique needs self.Direction is not built around particular.services or programs rather the.self-directed approach to service.delivery begins with the participant.designating what kind of life activities.are desired and what kind of help is.needed in order to attain those life.goals within the community while service.options may be selected from choices.already available through the existing.service delivery system the goal of self.direction is to allow participants to.create opportunities for themselves in.the social and economic communities in.which they live this slide describes the.difference between Nebraska's.traditional and self-directed models of.services you can see that in both models.the participant is at the center of the.wheel in the traditional model the.participant works closely with their.agency family and friends to determine.needs and services the agency then.recruits workers who report to the.agency the agency sets the.implementation plan of services that.will be delivered to the participant.specifies the workers salary and.benefits defines the workers normal work.hours schedule and ensures that the.worker receives all required training in.the self-directed model the participant.works with the family and supporters to.make decisions about their needs and.services the participant with support as.needed.the.recruits and manages their own workers.this includes describing the tasks that.will be provided to the participant.specifying salary and benefits and.benefits are optional in this case the.salary is provided within the parameter.described in Nebraska's home and.community-based waiver the participant.also works with the workers to assign a.flexible work our schedule that meets.the participants needs and finally the.participant either trains or arranges.for all worker training including those.trainings mandated by the state of.Nebraska self directed services and.their benefits on participants and their.families have been heavily researched.over the past 25 years.these studies consistently find that.participants who were able to.self-direct have a higher quality of.life.people who self-direct have more.positive outcomes including employment.independent living and community.inclusion self-direction is associated.with higher self-esteem.because people are able to choose the.lifestyle and preferences they desire.higher independence autonomy and control.all contribute to increased satisfaction.of services and supports we will now.take a brief look at the history of self.direction in the United States it's.important to note that self directed.models operate side-by-side with agency.managed service delivery models.participants and their families differ.in the extent to which they wish to take.on full management of their services.some participants want to exercise a.high level of control while others.prefer to have services and supports.managed by a provider agency.consequently participants are not faced.with an either/or proposition in.Nebraska instead they have a full range.of options available to them these.options began in 1972 with the.commencement of the Independent Living.movement in Berkeley California.Edie Roberts the director of the first.independent living movement.rolling quads organization created the.self-directed personal attendant care.concept by the 1980s self-direction was.prevalent in the personal care world as.a viable option in 1993 self-direction.options for home and community-based.services were included in the.president's health care reform.recommendations and proposed legislation.was introduced in Congress the.self-determination for persons with.developmental disabilities program was a.national program that began in 1995 to.help nineteen states implement a more.cost-effective system for serving people.with developmental disabilities while.simultaneously giving those individuals.and their families more choice in.determining the services they received.shortly thereafter 15 states were.afforded cash and counseling.demonstration funding by the Centers for.Medicare and Medicaid Services this.funding was used to support people with.physical disabilities and seniors with.high support needs in their pursuit of.self-directed service options the Robert.Wood Johnson Foundation sponsored two.research studies for their.self-determination project the studies.found that collaboration of all.disabilities stakeholders was critical.in terms of providing information and.other resources to participants in.supporting self-determination in the.community self-advocacy came of age in.the 1990s and was an especially.important ingredient to moving.self-direction into the forefront of.state division of developmental.disabilities policy considerations the.research studies cited the importance.that all system partners needed.additional training and adjusted roles.so that they did not become barriers to.self-determination as you all know.transportation matters it's a key to.independence finally small changes in a.person's life might be exceptionally.important to that person to their.quality of life it just depends on the.context.as you can see in the 1970s and 80s very.few states had self-directed programs.available to persons with developmental.disabilities or people with other.disabilities today this picture has.dramatically changed all states in the.country have some type of self-directed.program for people with developmental.disabilities physical disabilities or.seniors with high support needs we will.now take a look at the elements of.self-direction that are essential to.participants to plan and manage their.own services this pie chart depicts the.elements of a self-directed program as.found in Nebraska self-direction begins.with person centeredness the.person-centered plan is known in.Nebraska as the individual support plan.or ISP from there the participant has an.individual budget and that budget is.used to hire the staff necessary to.provide services and supports service.coordination provides information and.assistance and a financial management.service exists to receive worker.invoices and make sure they're paid the.participant exerts choice and control.over the services and supports this.begins with the individual support plan.developed with help from the team the.support plan is modified as needed with.assistance from the participants service.coordinator the participant authorizes.payment to their staff via Nebraska's.electronic records system which also.takes care of payroll and tax.withholdings participants are.responsible for managing their own.spending according to the services.described in their individual support.plan the electronic records system.generates utilization reports in order.to assist participants to monitor their.spending it's important before going.into self-direction that the participant.understands respects and accepts their.core responsibilities and authority this.includes supervising hiring.raining removing staff as needed fully.participating openly communicating with.both their workers and their service.coordinator accepting and following.program limitations asking for help when.it's needed and following the plan it's.very important that the participant and.a representative report what's working.and what's not to their service.coordinator in self-directed programs.participants may direct many or all of.their home and community-based services.including selecting and managing.independent providers for needed.services if a participant is unable to.manage their self-directed services or.feel apprehensive about doing so they.may choose a representative to assist.them this slide outlines representatives.responsibilities and the scope of.commitment to the participant a.representative is typically a family.member or close friend who assists the.participant in making decisions based on.their desired preferences a participant.still directs how and when services.aren't provided but a representative may.offer assistance with some of the tasks.the participant may find daunting for.example a representative may review.timesheets and talk to the provider or.take corrective action if an independent.provider fails to perform tasks in some.instances representatives may perform.all of these duties on behalf of the.participant not all participants want or.need a representative but such a person.can be helpful the service coordinator.will discuss this option with the.participant and if the participant.agrees that they would like this type of.assistance the service coordinator will.provide suggestions to the participant.on how to identify potential.representatives a representative may.also be someone who serves in other.roles to support the participant for.example a representative payee or legal.guardian the independent provider is an.essential.element of the self-directed model the.provider is managed by the participant.and/or their representative the.individual support plan describes the.tasks that the provider will be.performing in order to support the.participant the service authorization.describes the number of hours that the.provider will work Nebraska has an.electronic record system where the.provider submits their timecard.the independent provider is responsible.for preparing habilitation plans that.describe how they will meet the terms.and conditions of the individual support.plan and finally the independent.provider must document the service.delivery in therap Nebraska's electronic.records system the service coordinators.role within the self-directed model is.to provide information and assistance.the service coordinator assists the.participants to develop and/or modify.their individual support plan including.creating the plan to self-direct their.own services and supports the service.coordinator monitors the plan and.delivery of supports to the participants.the service coordinator also manages the.service authorization process and.provides guidance with recruiting hiring.and managing staff it is important to.note however that the service.coordinator does not perform these tasks.directly generally the service.coordinator monitors how self-direction.is going for the participant is the.participant happy do the services meet.their needs and is there anything else.that might make self-direction.work better for them the service.coordinator is also a resource to assist.the participant in looking for ways to.meet their needs by using informal.supports in addition to provider.supports.service coordinators provide information.and assist participants in connecting.with their communities the Nebraska.Department of Health and Human Services.or DHHS has a global role in overseeing.self-directed supports the division of.developmental disabilities over.seized individual support plans.including support budgets that are.submitted by service coordination.throughout the state the division of.Medicaid and long-term care approves.potential independent providers through.the Medicaid provider enrollment process.the developmental disabilities service.coordinator monitors participant budgets.through utilization reports supplied by.the electronic online records system the.developmental disabilities quality.review team ensures appropriate services.from service coordination and the fiscal.management service tasked with.reimbursing independent providers these.quality assurance activities serve to.ensure acceptable performance by the.system protect participants and improve.future services they are a major.component of a strong self-directed.system we will now take a look at the.elements of self-direction.that are essential to participants in.order that they can plan and manage.their own surfaces the National.Association for states United for Aging.and disabilities or NASA had developed a.series of probes to determine the.capacity of a participant to self-direct.should a participant to not be willing.or able to self-direct they can as noted.previously always have a representative.to assist them the probes are a means of.understanding if the participant has the.ability to make choices set goals.through their individual support plan be.aware of what is adequate or inadequate.support and make changes to how their.services are provided if necessary the.second premise is to assure that the.participant has the ability to monitor.their services independently or have.readily available assistance this is the.quality assurance function that the.participant themselves must be able to.manage nebraska is not using these.probes today this is simply an example.the probes began with the individual.support plan.what services does the participant want.and need included in the individual.support plan should be a discussion of.what other things would help the.participants be more independent that.they are not receiving now the probes go.into recruiting and hiring independent.providers to help the participants in.the home the participant must be able to.have a plan to train and supervise their.providers and give their providers.feedback about what's working and what's.not self directing participants must be.able to discuss with their independent.provider any concerns that they have.it's important that the participant has.a back-up plan in case the independent.provider calls in sick or fails to.appear does the participant know how.they would get their needs met.additionally does the participant know.how to respond in the event of an.emergency the probes ask if the.participant is willing to accept help.from their service coordinator if needed.and if they want to appoint a.representative who would that person be.again these probes for determining.capacity are not being used in Nebraska.today these are simple examples of what.determining capacity to self-direct.might look like the slide has a variety.of suggestions for the participants.interview with the prospective.independent provider it's important for.the participant and the representatives.if any to spend time thinking about.exactly what tasks they will want their.independent providers to perform.although flexibility is a key quality.for most independent providers a.potential job applicant will want some.specific information about what the.participant wants them to do for example.let's say the participant wants to have.an independent provider available at.dinner time does the participant want.the independent provider to cook dinner.for them teach them how to cook help.them cook or simply be in the vicinity.while they cook independently the.service coordinator is going to be a.great resource in helping participants.determine how best to advertise for.independent providers.one of the principal tasks of service.coordination is to monitor the.implementation of the individual support.plan and identify any causes for concern.the slide in the following slide detail.those causes for concern.as you can see they begin with how the.independent provider is supporting the.participants it's important for.participants to do their own performance.evaluations of their workers.some states recommend that the.participant conduct the first employee.evaluation approximately three months.after a new hire and then twice a year.after that these evaluations don't have.to be long but they are an important way.for both participant and their.independent provider to check in with.how things are going the service.coordinator reviews documentation and.and interviews with the participant.takes note of how often independent.providers failed to report to work how.often backup employees are used and how.often there are changes in employee's.service coordination keeps an eye on.family and participant satisfaction with.both quality and quantity of services is.the participants schedule flexible one.of the key pieces of self Direction is.that the participant is living the life.of their choosing and are the.independent providers assisting that.individual making sure the participant.is doing just that this also includes.engagement in community life the service.coordinator monitors the individual.budget to ensure that it is sufficient.and receives other complaints concerns.and suggestions from the participants.service coordination is equally.concerned about over and under.utilization of services if services are.underutilized the service coordinator.may ask questions to determine if health.and safety are being adequately.supported the service coordinator is.also monitoring the individual budget to.assure that it is sustainable over the.plan.the service coordinator closely monitors.any ongoing difficulty that a.participant may have in arranging for.services needed for health and safety.and/or the participants in ability to.supervise or fire an employee.effectively and finally the service.coordinator is active and monitoring the.individual support plan to ensuring that.it is implemented as it was developed.the service coordinator can always ask.for a meeting of the team to modify the.plan if needed the Nebraska Department.of Health and Human Services Division of.developmental disabilities has taken a.number of steps to enhance.self-direction in the state the next few.slides detail some of those activities.the state has recently expanded the.definition of who can be an independent.provider in addition to a provider being.a neighbor or friend a provider can now.be a family member as long as the family.member is not legally responsible in.other words the family member is legally.responsible and cannot be an independent.provider if they are the parent of a.child participant under age 19 a legally.appointed guardian to the participant or.the spouse of the participant the.Nebraska Department of Health and Human.Services Division of developmental.disabilities is focused on strengthening.the independent provider network to.build capacity and skills this includes.certain enrollment requirements.including CPR first aid abuse and.neglect training and either education or.experience independent providers must.have the ability to write habilitation.plans these plans detail the activities.that will be provided to the participant.in the implementation of the individual.support plan participants have full.authority to hire train schedules.supervised and dismissed their.independent provider as needed this.slide has a list of the waiver services.currently available for self-direction.in Nebraska the division of.developmental disabilities has two.mitad waiver applications to the Centers.for Medicare and Medicaid Services.included in those waiver applications is.a refinement of self-directed services.as you can see the self-directed aspect.of pre-vocational will end when the 2019.waiver amendments are approved the pre.vocational service will continue to.exist but will only be available from.agency providers starting with the.approval of the 2019 waiver amendments.the following day services will be.available for self-direction.habilitative community inclusion.supported employment follow along and.supported employment individual for.residential services supported family.living and independent living will be.available the other services much like.in current waivers that will be.available are assistive technology.consultative assessment environmental.modification assessment homemaker home.modifications transitional support for.participants moving out of an.institution transportation and respite.to ensure that self-direction remains a.viable desired option for participants.in Nebraska a number of questions may be.considered such as what's working and.what's not working right now in the.self-directed model in the state what.are the challenges for increasing the.number of people who choose.self-direction and suggestions for how.those challenges can be addressed are.there any health safety fraud and abuse.safeguards that need to be put into.place to protect their rights and safety.of participants the Nebraska Department.of Health and Human Services division of.developmental disabilities supports the.choices of individuals with.developmental disabilities and their.families within communities by promoting.and providing services that are.person-centered self-directed flexible.community inclusive and supportive of.the discovery and development of each.participant's unique gifts talents.abilities the division is committed to.work towards service options to ensure.that people with intellectual and other.developmental disabilities have the.opportunity to have fulfilling and.meaningful lives by allowing them to.contribute to and enjoy their.communities participants and their.families report a high level of.satisfaction through the increased.control over services the ability to.more fully integrate into their homes.and communities and the benefits of the.self-directed community life thank you.for viewing this presentation.

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