The Demonstration to Maintain Independence and Employment

1
The Demonstration to Maintain Independence and
Employment

• Assisting Individuals with Disabilities Remain
  Employed

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

3
Why DMIE?

• A persons 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.

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

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

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

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

8
For More Information

• Nanette Relave, DirectorCenter for Workers with
  Disabilities, NASMD
• NRelave_at_aphsa.org
• 202-682-0100 x241

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
• Were in a Catch-22 if you cant get your
  health better because the insurance doesnt cover
  services, then you cant get a full-time job, so
  then you cant 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 Crohns 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.

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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

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Kansas DMIE contacts

• Mary Ellen Wright
• Program Director
• Kansas Health Policy Authority
• MaryEllen.Wright_at_khpa.ks.gov
• [phone]
• Jean Hall
• External Evaluator
• University of Kansas
• jhall_at_ku.edu
• [phone]

18
Stay Well, Stay Working

• Minnesotas 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 N1000)

• 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)
22
22
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.
• Marys 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 wasnt 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

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Minnesota DMIE Contact

• MaryAlice Mowry, DirectorStay Well, Stay Working
• Maryalice.Mowry_at_state.mn.us
• [phone]

28
Texas DMIE

• Texas Department of State Health Services

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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)

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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
UT Austin Conduct independent evaluation DMIE
data system Recruitment
Harris County Hospital District Develop/ operate
DMIE Health System Provide match for
Medicaid-like services
State Oversight Federal Liaison Manage Project
33
Whos 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 Its 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
• [phone]
• dena.stoner_at_dshs.state.tx.us

39

• Hawaii Demonstration to Maintain Independence and
  Employment
• University of Hawaii - 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
• CMSHawaii Dept of Human ServicesHawaii Dept
  of Health
• Oahu WorkLinks
• University of Hawaii CDS
• Hawaii 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

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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 Supports
Intervention 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!

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Listen to Our Participants

• Ive lost over 25 pounds and feel better overall
  than I did prior to participatingmy 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_at_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.

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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.

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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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Iowas DMIE Project

• Target group - mentally ill inmates leaving
  prison with work history and ability to work.
• Grant will provide appropriate community mental
  health and vocational supports to keep mentally
  ill former inmates employed, independent, and in
  the community.
• Demonstrate higher employment rates, prevention
  of permanent disability.

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Iowa DMIE Multi-Agency partnership

• Project is a partnership between 4 agencies
• DHS, Iowa Workforce Development, Department of
  Corrections and University of Iowa.
• DMIE has a very rigorous evaluation methodology
• Experimental design Control groups
• Evaluation by University of Iowa
• Over 5 years - 28.2 Million State funds, 56.7
  million DMIE funds.

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Iowa DMIE Program

• Prior to release, intensive Life Skills training
  and Re-entry/transition planning with the inmate
  to prepare for community living (funded with 100
  state funds).
• DMIE - Community Supports
• Supported employment assistance help planning
  for and finding a job for when released.
  Includes supports for the employers.
• Medicaid coverage for mental health treatment and
  medications, includes intensive care management.
• Specialized community supervision.
• Employment is required for continued
  participation.

54
Iowa DMIE Contact

• Jennifer Vermeer, Assistant Medicaid
  DirectorIowa Medicaid EnterpriseIowa Department
  of Human Services
• JVermee_at_dhs.state.ia.us
• [phone]

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Questions?