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The Demonstration to Maintain Independence and Employment

The Demonstration to Maintain Independence and Employment. Assisting Individuals with Disabilities Remain Employed. What is DMIE?. DMIE provides medical and employment services to workers with potentially disabling health conditions.

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The Demonstration to Maintain Independence and Employment

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  1. The Demonstration to Maintain Independence and Employment Assisting Individuals with Disabilities Remain Employed 1

  2. What is DMIE? • DMIE provides medical and employment services to workers with potentially disabling health conditions. • The DMIE uses a rigorous experimental model, in order to determine the effect of health and employment supports on - • Health • Dependence on public benefits such as federal Social Security disability programs 2

  3. Why DMIE? • A person’s health affects their ability to work. • Many uninsured workers with disabilities lose employment and turn to federal assistance. • By 2003, disabled US workers accounted for nearly $65 billion of $77 billion in federal disability benefits. • Traditional Medicaid programs for people with disabilities do not provide “preventive care”. • DMIE offers a unique opportunity to keep workers healthy and working. 3

  4. “Gold Standard” Evaluation • Rigorous experimental/randomized control design to ensure strong, policy relevant data • Evaluation of quantitative and qualitative data, including: • Changes in health status • Income • Employment • Quality of Life • Disability Status • Cost-offsets • Program Cost effectiveness • Each state must have an independent evaluator • Mathematica Policy Research performs the national evaluation of DMIE 4

  5. Why Continue DMIE? • Preliminary findings suggest: • Potential to reduce public expenditures for disability benefits (less people applying) • Potential to reduce employer costs related to worker health problems • Provides data to support development of longer term reforms • May provide a replicable infrastructure of services to prevent disability 5

  6. Why Do We Need an Extension? • To move from a “one time experience” to conclusions, States need more time • Longer studies will produce – • Better measure of key outcomes (health, income, disability status, cost offsets, cost effectiveness) • Better data for policy development 6

  7. Need to Act Now • If there is a gap in funding, it will be difficult to restart these on-going projects • CMS must have time to amend grant awards • Revised terms and conditions will be needed • Match must be secured • Bi-annual State budgeting processes will need to anticipate extension or termination • States will need to amend vendor contracts 7

  8. For More Information • Nanette Relave, DirectorCenter for Workers with Disabilities, NASMD • NRelave@aphsa.org • 202-682-0100 x241 8

  9. The Kansas Demonstration to Maintain Independence & Employment Preliminary findings about participants’ health, service utilization and employment Jean P. Hall University of Kansas

  10. Target Population • Enrollees in the Kansas High Risk Pool health insurance program; DMIE provides Medicaid-like coverage as wraparound to the high risk plan, which has relatively limited coverage • Historically, people in the Kansas high risk pool have transitioned to federal disability benefits at a rate eight times that of the general population

  11. The Kansas High Risk Pool • Coverage of last resort for Kansans who are medically uninsurable in the private market (one of 34 pools nationally) • As a non-group plan, coverage is more expensive and less comprehensive than employer-based insurance • A 25 year old non-smoking female would pay $624/month in premiums for a plan with a $1500 deductible and 30% coinsurance

  12. Preliminary Findings About Study Participants • 80% have at least some college • Median annual income of $30,000 • 70% are self-employed • Despite risk pool coverage, 27% report having medical debt • Many report delaying or forgoing care due to lack of coverage or expense • Experience a range of serious and potentially disabling conditions including: diabetes, mental illnesses, cardiovascular disease, cancers and back and joint conditions

  13. From participants • About their coverage through the high risk pool: “We’re in a Catch-22: if you can’t get your health better because the insurance doesn’t cover services, then you can’t get a full-time job, so then you can’t get good insurance to help get your health better.” “I have car accident insurance, not wellness insurance.” • About the DMIE: It [the DMIE] increases your quality of life. You stay healthier because you have the enhanced benefits to help you stay healthy.

  14. Case Studies • Ms. A has Crohn’s disease and arthritis in her feet and ankles. The DMIE has allowed her to get the adaptive shoes and leg braces she needs to be able to work. She reports that, without the DMIE, she would have applied for SSDI and been fully disabled by now. • Mr. B says the DMIE has improved his life: “Being able to have that surgery for a detached retina and being able to see again was fantastic. I am a music teacher so it would have affected me greatly had I not had it repaired.”

  15. Need for an extension • Although a small minority of Americans acquire a disability immediately prior to applying for Social Security disability, the large majority experience a gradual worsening of medical conditions over time; health insurance coverage is a major factor in the decision to apply for disability benefits (Miller 2005). • Hadley (2003) found that improving health status from “poor to fair” to “good to excellent” would increase work efforts and earnings by 15 to 20%.

  16. Without an extension • Programs will not have sufficient time to demonstrate: • Prevention of transition to federal disability programs • Increases in work efforts and health status • An important part of the Ticket legislation, i.e., disability prevention, may not be realized and federal disability rolls will continue to grow

  17. Kansas DMIE contacts • Mary Ellen Wright Program Director Kansas Health Policy Authority MaryEllen.Wright@khpa.ks.gov (785) 296-5217 • Jean Hall External Evaluator University of Kansas jhall@ku.edu (785) 864-7083

  18. Stay Well, Stay Working Minnesota’s Demonstration to Maintain Independence and Employment

  19. The Commitment to a DMIE 1999 – Congressional Authorization 2003 – MN Legislature Authorized DMIE 2004 – MN Submits Proposal to CMS 2005 – Planning Grant Received 2006 – Protocols Approved (July) 2007 – Enrollment Began (January) 2008 – Enrollment Ends (8-31) 2009 – Six-Month Notification to Enrollees (3-31) 2009 – Demonstration Authority Ends (9-30)

  20. Desired Outcomes : Accessible, Responsive, Outcome Driven System • Community Mental Health Reform • Managed Care Pilots Integrating Health Care with Home and Community Based Services • Health Care Reform

  21. Who is Enrolled? (Current N=1000+) Most common mental health diagnoses: Depression Anxiety Disorder Bipolar Disorder 95% desire to keep working Average monthly income: $1,577.31 13% college graduate - 43% high school/GED 9% married; 27% divorced; 59% never married SF12* = 47 physical health, 36 mental health * SF-12 is a measurement of overall health, including mental health. Scale of 0-100 (poor to excellent, 50 avg. for general population)

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  23. Value of the DMIE • Building Stronger Community Capacity • Intervention Before “deep-end” Services • Evidence Based Practice and Person Centered

  24. DMIE Is Working • Kim was able to get back on her anxiety medications and reports more stability with her employer. • Kristin was drinking at work. She went through in-patient treatment and was able to keep her job. • Jeff has difficulty interacting with people due to schizophrenia. He was able to get a job as a delivery driver and is employed 30 hours per week. • Mary’s Fibromyalgia and late night shift were causing fatigue. An employment counselor helped her get a day shift close to home so she can continue working. • Todd knew he needed treatment that he wasn’t able to access and reported feeling suicidal. Through DMIE he received the treatment he needed. • At least 9 people have reported choosing DMIE instead of applying for a disability determination.

  25. Moving Forward “This is good common-sense policy: providing preventive health coverage to working individuals with serious medical conditions before such conditions worsen to disabling level.” Senator Patrick Moynihan, Congressional Record 11-99

  26. What to Leave Here With… “For the first time in over a year, I feel hope. With the services and support DMIE offers, I can begin to manage my chronic conditions better, find a permanent job, catch up financially and improve my life.” Barb - DMIE participant 3/20/08

  27. Minnesota DMIE Contact • MaryAlice Mowry, DirectorStay Well, Stay Working • Maryalice.Mowry@state.mn.us • (651) 431-2384

  28. Texas DMIE Texas Department of State Health Services

  29. Current Reality • 28 percent of working adult Texans are uninsured • Uninsured Texans with disabilities turn to federal programs for help when they become unemployed. • This increases federal costs and erodes the local tax base which supports health care. • 250,000 working age Texans with disabilities receive SSI (average of $412/ mo per person in 2005) • 380,000 Texas workers with disabilities receive SSDI (average of $924/mo in 2005) • 345,500 working age Texans with disabilities were on Medicaid in 2007.  Expenditures were $3.5 billion. (In Harris County 48,600 cost $375.5 million)

  30. Texas DMIE • A model which can work in states where county governments address the health needs of low income workers • Largest study population among DMIE projects (over 1600 participants) • Randomized controlled trial • Intervention group receives enhanced medical and vocational services

  31. Current Texas Site: Houston

  32. State / Local Partnership Harris County Hospital District Develop/ operate DMIE Health System Provide match for Medicaid-like services UT Austin Conduct independent evaluation DMIE data system Recruitment State Oversight Federal Liaison Manage Project

  33. Who’s in Texas DMIE? • Adults (21 – 60) with disabling conditions • Severe mental illness (schizophrenia, bi-polar disorder, major depression) – 12%, or • Major physical conditions (e.g., diabetes, heart disease, MS, etc.) PLUS a behavioral health illness (depression, etc.) – 88% • Low income – 90% are below 200% poverty, 60% are below 100% poverty • Limitations in performing daily living tasks (40%) • A strong desire to continue working (80-90%) • Part or full-time jobs (20% are health care workers) • At significant risk of dependence (over 400 candidates applied for disability before they could be recruited into the study)

  34. Supporting Wellness • Health services (physician, hospital, etc. ) • Enhanced health services • Prescription medicine • Enhanced psychological and neuropsychological assessments • Improved access to outpatient mental health services (expedited office or outpatient visits) • Chemical dependency treatment services • Expanded Durable Medical Equipment • Preventative and restorative dental treatment

  35. Supporting Independence • Individual planning addressing life and health issues • Advocacy, direct services, motivational interviewing, coordination and intervention • Assistance in connecting to other community resources • Employment/Vocational supports including: • Vocational Assessment/Evaluation • Collaboration with an Employer • Vocational Support Groups • Collaboration with Family/Friends • Vocational Treatment Planning/Career Development • Vocational Counseling 

  36. Texas DMIE Enrollment

  37. How It’s Working • Linking workers to vital health care services • Providing help to gain, keep, improve employment • Building upon local systems of care by better coordinating existing resources • Hundreds are now getting help. Success stories include: • Mental health care and employer education result in secure and stable job for formerly suicidal person • Orthopedic shoes, health and job counseling allow a severe diabetic to keep working • Health counseling, career planning result in full-time job for formerly unemployed person with multiple physical/mental disabilities

  38. Future Texas Plans Texas plans to extend / expand DMIE, should extension be included in the federal budget • Continue Houston project through 2012 • Add second site - Bexar County (San Antonio) – important to determine if success can be replicated in Texas For more information contact: Dena Stoner, State Project Director (512) 206-4851 dena.stoner@dshs.state.tx.us

  39. Hawaii Demonstration to Maintain Independence and Employment University of Hawai`i - Center on Disability Studies April 15, 2008

  40. Partnership for a Healthy WorkforceStrategy: Partner with employers to find ways to maintain a healthy workforce Committed Employers - $6.7 Million: Hawaii Business Health Council Times Supermarket Roberts Hawaii Longs Drug Store Roberts Hawaii Hawaiian Electric Company, Inc Central Pacific Bank …and many more Committed Agencies - $9.1 Million: CMSHawai`i Dept of Human ServicesHawai`i Dept of Health Oahu WorkLinks University of Hawai`i – CDS Hawai`i DLIR HI Division of Voc. Rehab Hawaii Disability Rights Center

  41. Why do Employers Care? Prevalence of diabetes in U.S. • Approximately 17.5 million are diagnosed • National cost of diabetes exceeds $174 Billion • $116 billion in excess medical expenditures • $58 billion in reduced national productivity Prevalence of diabetes in Hawaii • About 107,000 people living with diabetes • Estimated annual costs are more than $1 billion • $764,400,000 for medical costs • $273,600,000 for indirect expenses – loss of productivity Source: Diabetes Care, Volume 31, Number 3, March 2008 & National Diabetes Education Program www.ndep.nih.gov & National Diabetes Education Program, NIDDK, National Diabetes Fact Sheet HHS, NIH, 2005, www.ndep.nih.gov

  42. A Possibility for Prevention Goal:Develop, implement, and evaluate interventions that are intended to improve health care coverage and employment services for working adults with diabetes and potentially disabling conditions Target Population: Individuals diagnosed with diabetes or has a Hemoglobin A1c 6.5+ Employed adults (40+ hrs. per month) Resident of Oahu

  43. Life Coaching – Benefits and SupportsIntervention:Off-site diabetes self-management support services. Participants will meet with: • Pharmacist (Medication Therapy Management) • Life Coach (Use of a laptop and online coaching tool to track goals) Financial Compensation: • Medical, drugs, and supplies related to diabetes Other optional services include: • Certified Diabetes Educator • Dietitian • Fitness Membership

  44. Desired Outcomes for our Community People working and living with diabetes will: Improved health and productivity Increase work hours Reduce absenteeism Reduce employee turnover Improve job satisfaction and morale Diabetes is Preventable and Treatable!

  45. Listen to Our Participants “I’ve lost over 25 pounds and feel better overall than I did prior to participating…my HbA1c has dropped from 7.0 to 6.2 percent on my last blood test.” – Rodney "It has given me positive feedback, encouraged me to set measurable short term goals to keep that positivity going strong."  – Anonymous "Great program, kept me motivated and thinking about what I can do to help myself live a better/healthier life." – Brian "With a life coach, you will have someone who can provide a different perspective, help set goals, and provide other resources that may help you control this affliction.“ – Anonymous

  46. Mahalo nui loa! Contact information: Rebecca Rude Ozaki, Ph.D. 1-808-956-9376 rozaki@hawaii.edu www.livehealthyworkwell.org University of Hawaii at Manoa – Center on Disability Studies 1776 University Ave., UA 4-6 Honolulu, HI 96822

  47. Iowa DMIE: Former inmates with mental illness - Re-entry employment and support Jennifer Vermeer Assistant Medicaid Director Iowa Medicaid Enterprise Iowa Department of Human Services

  48. Iowa DMIE – the benefit • DMIE Purpose – prevent disability and lifetime dependence on disability programs; support independence and employment. • Iowa is focusing on a unique population – individuals re-entering community from prison, with mental illness who are willing and able to be employed, but needing supports. • Studying the outcomes of this population will provide significant national benefit, because all states face these problems.

  49. Iowa – Need DMIE grant extension to start • Unlike the other states, Iowa has just received grant approval. • Iowa needs the 5 year extension in order to start and implement our program. • No federal funds will be used for the prison services prior to release. Iowa is investing a significant 100% state funds contribution to the project for the re-entry services needed prior to release from prison.

  50. The Problem: Lack of supports land mentally ill in prison • Nationally, as many as 1 in 5 prison/jail inmates are mentally ill. In Iowa, 1 in 3 inmates are mentally ill. • Former inmates have little to no access to mental health treatment outside prison, and are far less likely to be employed than other inmates (29% for mentally ill vs. 69% for other inmates) . • Without supports, more likely to eventually become permanently disabled and dependent upon public assistance programs. • National interest in ‘re-entry’ or rehabilitation programs for those coming out of prison. (‘Second Chance Act’ just signed). Mentally ill inmates pose particularly difficult challenges for re-entry and success in community.

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