DEVELOPMENTAL DISABILITIES 2010:TRENDS, TECHNOLOGIES & UNCERTAINTIES
IN THE STATESDavid Braddock, Ph.D., Professor and Executive Director,
Coleman Institute for Cognitive DisabilitiesAssociate Vice President, University of Colorado System
2010 NASDDDS Annual ConferenceArlington, Virginia
November 18, 2010
Presentation © 2010 David Braddock
2
PRESENTATION OUTLINE
I. CURRENT TRENDS IN I/DD SERVICES IN THE U.S.
II. INTERLUDE ON EMERGING SMART HOMES & PERSONAL SUPPORT TECHNOLOGIES
III. BACK TO REALITY: ECONOMIC UNCERTAINTY IN THE STATES
3
FINANCIAL CONDITIONS IN THE STATES
• TOTAL INFLATION-ADJUSTED PUBLIC I/DD SPENDING DECLINED IN THE US IN 2009.
• THIS IS THE FIRST SUCH DECLINE SINCE WE BEGAN COLLECTING FEDERAL SPENDING DATA IN 1972, STATE BY STATE DATA FROM 1977, AND PROBABLY SINCE THE GREAT DEPRESSION.
4
TOTAL I/DD SPENDING DECLINED IN 2009
Source: Braddock, D., State of the States in Developmental Disabilities, 2010, preliminary.
7778
7980
8182
8384
8586
8788
8990
9192
9394
9596
9798
9900
0102
0304
0506
0708
09
Fiscal Year
$0
$10
$20
$30
$40
$50
$60
Bil
lio
ns
of
20
09
Do
lla
rs
$13.5
$28.3
$43.1
$51.6$52.9$53.1
5
ANNUAL % CHANGE IN INFLATION-ADJUSTED I/DD SPENDING IN THE U.S.: 1978-09
Source: Braddock, D., Coleman Institute and Department of Psychiatry, University of Colorado, 2010.
78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09Fiscal Year
-2%
0%
2%
4%
6%
8%
10%
12%
14%
Per
cen
t R
eal
Ch
ang
e
7.0%
3.2%
11.7%
7.0%
2.4%
6.5%
1.7%0.9%
2.3%
-0.1%
6
THE AVERAGE ANNUAL RATE OF TOTAL I/DD SPENDING HAS STEADILY DECLINED BY DECADE
Source: Braddock, D., Coleman Institute and Department of Psychiatry, University of Colorado, 2010.
1970s 1980's 1990's 2000'sFiscal Period
-4%
-2%
0%
2%
4%
6%
8%
10%
12%
14%
% R
EA
L C
HA
NG
E 7.0%
5.7%4.4%
2.5%
7
NUMBER OF STATES WITH INFLATION-ADJUSTED CUTS IN I/DD SPENDING: 1978-2009
Source: Braddock, D., State of the States in Developmental Disabilities, 2010, preliminary.
(e)
1978 - 7 1989 - 5 2000 - 6
1979 - 6 1990 - 4 2001 - 10
1980 - 18 1991 - 6 2002 - 2
1981 - 15 1992 - 11 2003 - 20
1982 - 14 1993 - 18 2004 - 16
1983 - 17 1994 - 8 2005 - 21
1984 - 10 1995 - 6 2006 - 23
1985 - 5 1996 - 10 2007 - 15
1986 - 5 1997 - 8 2008 - 22
1987 - 7 1998 - 4 2009 - 25
1988 - 6 1999 - 10
8
Source: Braddock, D., State of the States in Developmental Disabilities, 2010, preliminary.
State % Change State % Change State % ChangeOregon 12% Utah 2% Michigan -1%District of Columbia 11% Mississippi 2% Arizona -1%Nevada 9% Massachusetts 2% New York -2%Louisiana 8% Illinois 1% Missouri -2%Alaska 7% New Mexico 1% Alabama -2%Washington 7% Virginia 1% Indiana -3%North Dakota 5% Ohio 0% Maryland -4%Arkansas 5% Maine 0% Iowa -4%New Hampshire 4% Kansas 0% Hawaii -6%California 4% Minnesota -1% Georgia -7%Connecticut 4% South Dakota -1% Montana -7%Colorado 3% Nebraska -1% Texas -7%Pennsylvania 3% Wyoming -1% Florida -8%North Carolina 3% New Jersey -1% Idaho -9%Vermont 2% Tennessee -1% Rhode Island -10%Delaware 2% Kentucky -1% South Carolina -11%West Virginia 2% Wisconsin -1% Oklahoma -12%
UNITED STATES -0.1%
INFLATION-ADJUSTED GROWTHIN I/DD SPENDING IN THE STATES, 2008-09
9
INSTITUTION SPENDING GROWTH IS NEGATIVE OVER THE LAST TWO DECADES
Source: Braddock, D., Coleman Institute and Department of Psychiatry, University of Colorado, 2010.
1970s 1980's 1990's 2000'sFiscal Period
-4%
-2%
0%
2%
4%
6%
8%
% R
EA
L C
HA
NG
E
5.5%
1.5%
-1.9%-2.6%
10
COMMUNITY SERVICES SPENDING ASCENDED 1970-90, THEN GROWTH SLOWED
Source: Braddock, D., Coleman Institute and Department of Psychiatry, University of Colorado, 2010.
1970s 1980's 1990's 2000'sFiscal Period
-4%
-2%
0%
2%
4%
6%
8%
10%
12%
14%
% R
EA
L C
HA
NG
E
11.5%12.6%
8.3%
3.9%
11
REDUCTIONS IN STATE ONLY FUNDING: FY2009
Source: Braddock, D., State of the States in Developmental Disabilities, 2010, preliminary.
-32%
-20%
-12%
-0.1%
9%-40% -30% -20% -10% 0% 10% 20%
AlabamaSouth Carolina
IdahoRhode Island
OklahomaTexas
FloridaIndianaArizona
MichiganTennessee
West VirginiaUtah
MontanaGeorgia
MassachusettsMaine
HawaiiNew JerseyMississippi
VermontIowa
MinnesotaWisconsin
OregonNebraskaMaryland
South DakotaDistrict of Columbia
MissouriNew Mexico
LouisianaVirginia
UNITED STATESIllinois
New YorkColoradoWyoming
KansasPennsylvania
ArkansasDelaware
New HampshireWashington
North CarolinaOhio
CaliforniaAlaska
ConnecticutNorth Dakota
NevadaKentucky
State only funding includes state Medicaid matching funds, state general fund, special state funds and local government funding.
12
--STATE INSTITUTIONS
--HCBS WAIVER
--FAMILY SUPPORT
-Pilot Study with NASDDDS
--SUPPORTED LIVING
--SUPPORTED EMPLOYMENT
--US CROSS-DISABILITY SPENDING
REVIEW OF CURRENT I/DDTRENDS IN THE STATES
13
INSTITUTIONAL RESIDENTS WITH I/DDIN THE U.S.: 1848-2009
Source: Braddock, D., State of the States in Developmental Disabilities, 2010, preliminary.
*Excludes nursing facilities [32,570 persons in 2009].
18481853
18581863
18681873
18781883
18881893
18981903
19081913
19181923
19281933
19381943
19481953
19581963
19681973
19781983
19881993
19982003
0
50,000
100,000
150,000
200,000
250,000
Dai
ly C
ensu
s
10
194,650
38,547
33,795
2006
20092006
2009
14
CUMULATIVE CLOSURES OFSTATE-OPERATED 16+ INSTITUTIONS
Source: Braddock, D., State of the States in Developmental Disabilities, 2010, preliminary.
UNITED STATES
1848 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010
Year
0
20
40
60
80
100
120
140
160
Nu
mb
er
of
Clo
su
res
0 0 28 10
25
48
80
116
131
145
15
MOST RECENT INSTITUTIONALCLOSURES: 2007-10
Source: Braddock, D., State of the States in Developmental Disabilities, 2010, preliminary.
State Institution
Year Built/ Became
MR Original Use#
Residents*Year of Closure Alternate Use
CALIFORNIA Agnews 1855/1966 MI Facility 411 2009 Undetermined
ILLINOIS Howe 1973 MR Facility 251 2010 Undetermined
INDIANA Ft. Wayne 1879 MR Facility 120 2007To be demolished
MARYLAND Rosewood 1888 MR Facility 153 2009 University
OREGON Eastern Oregon 1909 MR Facility 50 2009Community I/DD Program
*When closure announced
16
STATES WITH NO STATE-OPERATEDI/DD INSTITUTIONS
Source: Braddock, D., State of the States in Developmental Disabilities, 2010, preliminary.
1. DISTRICT OF COLUMBIA (1991)
2. NEW HAMPSHIRE (1991)
3. VERMONT (1993)
4. RHODE ISLAND (1994)
5. ALASKA (1997)
6. NEW MEXICO (1997)
7. WEST VIRGINIA (1998)
8. HAWAII (1999)
9. MAINE (1999)
10.MINNESOTA (2000)
11. INDIANA (2007)
12.OREGON (2009)
17
WHO’S NEXT?
Source: Braddock, D., State of the States in Developmental Disabilities, 2010, preliminary.
1 Nevada 482 Montana 643 Michigan 704 Delaware 765 Wyoming 836 Idaho 967 Colorado 1038 Arizona 1239 North Dakota 123
10 South Dakota 146
SMALLEST INSTITUTIONAL CENSUS, 2009
18
WHO’S NOT?
Source: Braddock, D., State of the States in Developmental Disabilities, 2010, preliminary.
• North Carolina census increased by 99 persons since 2006
1 Texas 4,8992 New Jersey 2,7034 Illinois 2,3083 California 2,1945 North Carolina 1,7046 New York 1,4927 Ohio 1,4238 Mississippi 1,3719 Pennsylvania 1,253
10 Virginia 1,184
LARGEST CENSUS, 2009
19
Utilization Rate: 193 per 100,000
INDIVIDUALS WITH I/DD IN OUT-OF-HOME PLACEMENTS IN THE U.S., 2009
Source: Braddock, D., State of the States in Developmental Disabilities, 2010, preliminary.
36%
10%
6%
4%6%
Total: 590,973 Persons
7-15 Persons58,127
Nursing facilities 16+32,570
United States
Group, foster, host homes, apartments
211,880 Persons
Supported Living228,039 Persons
6/Fewer Persons74%
State inst.16+33,795
Private 16+26,562
16+ Persons16%
38%
20
INDIVIDUALS WITH I/DD INOUT-OF-HOME PLACEMENTS IN 2009
SMALL NEW ENGLAND STATES(MAINE, NEW HAMPSHIRE, RHODE ISLAND, VERMONT)
Source: Braddock, D., State of the States in Developmental Disabilities, 2010, preliminary.
Total Consolidated General Population in 2009: 4.3 million.
71%
21%
3%4%
Total: 10,053 Persons
Nursing facilities382
Group, foster, host homes, apartments
7,135 Persons
Supported Living2,148 Persons
6 Persons or Fewer92%
Private 16+75 (<1%)
16+ Persons5%
7-15 Persons313
21
MOST EXTENSIVE UTILIZATION OF7-15 PERSON SETTINGS*
Source: Braddock, D., State of the States in Developmental Disabilities, 2010, preliminary.
1 Illinois 31%2 New York 29%3 South Dakota 22%4 North Dakota 22%5 Montana 20%6 Indiana 20%
Small New England States 3%UNITED STATES 10%
*Percentage of total served in out-of-home residential services
22
GROWTH RATE OF COMMUNITY PLACEMENTS FOR SIX OR FEWER PERSONS DECLINES 50%: 2006-09
UNITED STATES
Source: Braddock, D., State of the States in Developmental Disabilities, 2010, preliminary.
95 96 97 98 99 00 01 02 03 04 05 06 07 08 09Fiscal Year
0
100,000
200,000
300,000
400,000
500,000
Nu
mb
er o
f P
erso
ns
179,495240,356
289,103337,895
380,216439,919
Persons in Residential Settings for 6 or Fewer Persons
Average annual increase 1995-2006: 10%
5%
23
MEASURING STATES’ COMMITMENTTO I/DD SERVICES
Fiscal effort is a ratio that can be utilized to rank states according to the proportion of their total statewide personal income devoted to the financing of I/DD services.
Fiscal effort is defined as a state’s spending for I/DD services per $1,000 of total statewide personal income.
24
FISCAL EFFORT FOR I/DD SERVICES INTHE TOP TEN AND BOTTOM TEN STATES 2009
Source: Braddock, D., State of the States in Developmental Disabilities, 2010, preliminary.
1 New York $9.53 42 Utah $3.002 Maine $8.30 43 Kentucky $2.913 Connecticut $7.76 44 Maryland $2.904 Minnesota $7.57 45 Virginia $2.755 North Dakota $7.53 46 Alabama $2.296 Louisiana $7.43 47 Colorado $2.257 Ohio $6.98 48 Georgia $2.168 Iowa $6.62 49 Florida $2.149 Rhode Island $6.35 50 Texas $2.04
10 Vermont $6.25 51 Nevada $1.55
TOP 10 BOTTOM 10
25
FISCAL EFFORT FOR I/DD SERVICES INTHE STATES: 2009
Source: Braddock, D., State of the States in Developmental Disabilities, 2010, preliminary.
1 New York $9.53 18 Delaware $5.04 35 South Carolina $3.542 Maine $8.30 19 Arkansas $4.82 36 Washington $3.513 Connecticut $7.76 20 Idaho $4.68 37 Missouri $3.484 Minnesota $7.57 21 South Dakota $4.62 38 Oklahoma $3.465 North Dakota $7.53 22 Arizona $4.54 39 New Jersey $3.426 Louisiana $7.43 23 Mississippi $4.32 40 Hawaii $3.197 Ohio $6.98 24 Nebraska $4.26 41 Illinois $3.138 Iowa $6.62 25 Massachusetts $4.26 42 Utah $3.009 Rhode Island $6.35 26 Kansas $4.25 43 Kentucky $2.91
10 Vermont $6.25 27 Tennessee $4.17 44 Maryland $2.9011 District of Columbia $6.11 28 Indiana $4.14 45 Virginia $2.7512 Pennsylvania $5.78 29 North Carolina $4.08 46 Alabama $2.2913 West Virginia $5.66 30 Alaska $3.99 47 Colorado $2.2514 Wisconsin $5.45 31 Montana $3.85 48 Georgia $2.1615 New Mexico $5.44 32 California $3.83 49 Florida $2.1416 Oregon $5.18 33 Michigan $3.83 50 Texas $2.0417 Wyoming $5.16 34 New Hampshire $3.78 51 Nevada $1.55
UNITED STATES: $4.35
26
PUBLIC SPENDING FORI/DD LONG-TERM CARE
HOME AND COMMUNITY
BASED SERVICES
(HCBS) WAIVER
27
FEDERAL HCBS WAIVER SPENDING SURPASSED ICF/MR SPENDING IN 2001
Source: Braddock, D., State of the States in Developmental Disabilities, 2010, preliminary.
73 75 77 79 81 83 85 87 89 91 93 95 97 99 01 03 05 07 09
Fiscal Year
$0
$5
$10
$15
$20
Bil
lio
ns
of
20
09
Do
lla
rs
$9.4$8.5
$7.9
$7.7
$10.0
$11.9
$15.5
ICF/MR
HCBS Waiver
Intercept(2001)
28
GROWTH OF FEDERAL HCBS WAIVER SPENDING BY DISABILITY GROUP: 1997-2007
Source: Braddock, D. (in press). Public spending for services to persons with disabilities in the United States. Boston: Federal Reserve Bank of Boston.
97 98 99 00 01 02 03 04 05 06 07
Fiscal Year
$0
$2
$4
$6
$8
$10
$12
$14
$16
Bil
lio
ns o
f 2007 D
oll
ars
$0.04$0.75 $0.81 $0.97 $1.10 $1.24 $1.27 $1.42 $1.59 $1.58 $1.69 $1.82
$5.04$5.78
$6.84$7.43
$8.09
$9.22$10.01
$10.91 $11.14 $11.49$12.17
Intellectual DisabilityPhysical DisabilityMental Health
UNITED STATES
Mental Health Waivers ($41.5 million)
29
TOTAL DISABILITY SPENDINGIN THE U.S.: 1997-2007
97 98 99 00 01 02 03 04 05 06 07FISCAL YEAR
$0
$100
$200
$300
$400
$500
$600
$700
BIL
LIO
NS
OF
200
7 $S
$400.8$431.8
$464.4
$512.2$542.1 $559.0
Source: Braddock, D. (in press). Public spending for services to persons with disabilities in the United States. Boston: Federal Reserve Bank of Boston.
30
DISABILITY SPENDING IN THE U.S. BY ACTIVITY CATEGORY: 1997-2007, INFLATION ADJUSTED
97 98 99 00 01 02 03 04 05 06 07
Fiscal Year
0
50
100
150
200
250
Bill
ion
s o
f 20
07 D
olla
rs
$136$143 $145 $149 $153
$161 $163 $167 $168$165
$167
$121 $124 $127 $128 $131$139
$145$151 $156
$158 $162
$89 $92 $93$99
$106$118
$124$130
$137$140
$147
$55$61 $66 $70 $73 $78 $80 $81 $82 $82 $82
Long Term Care*Income Maintenance
Health CareSpecial Education
*Excludes Long Term Care funding that has been included with Income Maintenance totals.
Source: Braddock, D. (2010). Public spending for services to persons with disabilities in the United States. Washington, DC: Federal Reserve Bank of Boston.
31
PERCENT INSTITUTION/NURSING HOME SPENDING BY DISABILITY GROUP
Physical Disability Mental Illness I/DD0%
20%
40%
60%
80%
100%
Pe
rce
nt
for
Ins
titu
tio
na
l S
pen
din
g 81%
49%
32%
78%
44%
25%
75%
43%
20%
1997 2002 2007
Source: Braddock, D. (2010). Public spending for services to persons with disabilities in the United States. Washington, DC: Federal Reserve Bank of Boston.
32
MEDICAID INSTITUTIONAL/NURSING FACILITY SPENDING VS COMMUNITY SPENDING
Physical Disability Mental Illness I/DD0%
20%
40%
60%
80%
100%
Pe
rce
nt
for
Ins
titu
tio
na
l S
pe
nd
ing 83%
73%
42%
81%
64%
32%
73%
51%
26%
1997 2002 2007
Source: Braddock, D. (2010). Public spending for services to persons with disabilities in the United States. Washington, DC: Federal Reserve Bank of Boston.
33
TRENDS IN FAMILY AND PERSONAL SUPPORTS
• FAMILY SUPPORT
• SUPPORTED LIVING
• SUPPORTED EMPLOYMENT
34
FAMILY SUPPORT DEFINED
1. Respite services2. Cash subsidy (financial support)3. In-home support, education, and training4. Assistive and medical technology5. Health and related professional services6. Family training/counseling7. Transportation8. Case management/service coordination9. Recreation/leisure10.Other family support
Source: Braddock, D., State of the States in Developmental Disabilities, 2010, preliminary.
35
STATES REPORT CONTINUING GROWTH IN FAMILIES SUPPORTED: 1988-2009
Source: Braddock, D., State of the States in Developmental Disabilities, 2010, preliminary.
88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 090
100,000
200,000
300,000
400,000
500,000
600,000
Nu
mb
er o
f F
amil
ies
Su
pp
ort
ed
113,807
212,558
280,988
319,591
372,847393,598
438,008
490,319
$3.77 BILLION, 2009
36
BUT ONLY 17% OF FAMILIES RECEIVED I/DD AGENCY SUPPORT IN 2009
Sources: Braddock, D., State of the States in Developmental Disabilities, 2010, preliminary;family caregivers estimated from Survey of Income and Program Participation (SIPP) data (Fujiura, 1998).
88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09
FISCAL YEAR
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0M
ILL
ION
S O
F F
AM
ILIE
S
0.10 0.16 0.28 0.37 0.42 0.49
2.40 2.482.60
2.75 2.81 2.88
Total I/DD Caregiving FamiliesFamilies Supported by State I/DD Agencies
37
HCBS WAIVER PROVIDED 73% OF THATI/DD FAMILY SUPPORT SPENDING IN 2009
Source: Braddock, D., State of the States in Developmental Disabilities, 2010, preliminary.
86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09FISCAL YEAR
$0
$1,000
$2,000
$3,000
$4,000
$5,000
MIL
LIO
NS
OF
2009 D
OL
LA
RS
33%40%
53%65%
73%
$168$410
$827
$1,606
$2,678
$3,033
$3,782
Total Family Support SpendingFederal-State Waiver Spending Share (%)
38
Source: Braddock, D., State of the States in Developmental Disabilities, 2010, preliminary.
StateFamilies
Supported StateSubsidy Per
Family1 Michigan 7,125 Utah $10,2992 New Jersey 5,685 Illinois $7,9203 South Carolina 3,627 Minnesota $6,8114 Connecticut 3,578 North Dakota $5,5715 Tennessee 3,403 Nevada $4,5026 Texas 3,060 New Mexico $4,3377 Minnesota 2,781 Iowa $4,2498 Washington 2,311 Florida $3,9089 Oklahoma 2,299 Delaware $3,294
10 Louisiana 1,523 Louisiana $3,27211 Kansas 1,418 Rhode Island $3,26112 Maine 545 Michigan $2,59813 Nevada 492 Oklahoma $2,58814 Illinois 413 Kansas $2,51615 Iowa 353 Arizona $2,50917 Arizona 181 Texas $1,87018 New Mexico 164 Washington $1,71119 North Dakota 95 Tennessee $1,42916 Florida 85 New Jersey $1,31520 Delaware 54 South Carolina $1,13421 Rhode Island 50 Maine $1,10122 Utah 6 Connecticut $917
U.S. 39,248 U.S. $2,328
22 STATES HAVE I/DD CASH SUBSIDIES
39
SELF-DIRECTED COMPONENT OF SUPPORTED LIVING IN NEW YORK STATE:1988-09
NEW YORK
8889
9091
9293
9495
9697
9899
0001
0203
0405
0607
0809
Fiscal Year
$0.0
$100.0
$200.0
$300.0
$400.0
Mil
lio
ns
of
20
09
Do
lla
rs
$4.6
$55.8
$299.4$325.1
$2.7$5.7 $12.4
Total Adjusted Supported Living SpendingSelf-Directed Portion of Supported Living Spending
Total Supported Living $s
Self-Directed $
Source: State of the States/NASDDDS pilot study of individual and family support, preliminary data, 2010.
40
NEW YORK SELF-DIRECTED SUPPORTED LIVING SPENDING INCREASES FOURFOLD 2006-09
Source: State of the States/NASDDDS pilot study of individual and family support, preliminary data, 2010.
2006 2007 2008 2009
0.5% 1.0% 1.7% 2.2%
1.6% 3.3% 3.9% 7.2%
ADULTS CONTROL THEIR BUDGET; HIRE/FIRE STAFF
ID ADULT LIVES IN THE FAMILY HOME
ID ADULT LIVES IN OWN, OTHER HOME
41
“While supported employment has made significant gains since its formal introduction in 1984 (P.L. 98-527), segregated services continue to outpace the growth of supported employment.”
(Rusch & Braddock, Research and Practice for Persons with Severe Disabilities, 2004)
SUPPORTED EMPLOYMENT
42
NUMBER OF SUPPORTED EMPLOYMENT WORKERS PLATEAUS 2002-09
Source: Braddock, D., State of the States in Developmental Disabilities, 2010, preliminary.
86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09Fiscal Year
0
25,000
50,000
75,000
100,000
125,000
150,000
Nu
mb
er o
f S
up
po
rted
/Co
mp
etit
ive
Wo
rker
s
6,642
74,191
97,100
114,855
109,285
111,388115,474
SUPPORTED EMPLOYMENT WORKERS WERE
21% OF TOTAL DAY/WORK PARTICIPANTS IN 2009
43
HCBS WAIVER SPENDING PROVIDED 68% OF I/DD SUPPORTED EMPLOYMENT SPENDING IN 2009
Source: Braddock, D., State of the States in Developmental Disabilities, 2010, preliminary.
29%49%
68%
$437
$669
$863
$783$829
92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09FISCAL YEAR
$0
$200
$400
$600
$800
$1,000
$1,200
MIL
LIO
NS
OF
20
09
DO
LL
AR
S
Total Supported Employment SpendingFederal-State Waiver Spending
44
TOP TEN STATES’ GROWTH IN SUPPORTED EMPLOYMENT WORKERS FROM 2006 TO 2009
Source: Braddock, D., State of the States in Developmental Disabilities, 2010, preliminary.
1 Michigan 1,7492 California 1,5273 Maryland 1,0694 North Carolina 6125 Washington 5826 Florida 5447 Iowa 5008 Indiana 4789 Pennsylvania 417
10 Oklahoma 384
45
NUMBER OF SUPPORTED EMPLOYMENT WORKERS IN WASHINGTON STATE 1986-2009
Source: Braddock, D., State of the States in Developmental Disabilities, 2010, preliminary.
86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09Fiscal Year
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
Nu
mb
er
of
Su
pp
ort
ed/C
om
pet
itiv
e W
ork
ers
896
2,410
3,017
3,608
4,6874,933
5,379
SUPPORTED EMPLOYMENT WORKERS WERE
62% OF TOTAL DAY WORK PARTICIPANTS IN 2009
46
I/DD PARTICIPANTS IN DAY PROGRAMS, SHELTERED WORK & SUPPORTED/COMPETITIVE EMPLOYMENT
88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09Fiscal Year
0
100
200
300
400
500
600
700
Th
ou
sa
nd
s o
f D
ay
/Wo
rk P
art
icip
an
ts
259
405
489 501528
551
109
201
258281
299326
128 130 117
108
117
109.321
74 115
113
111
115.5
Total Day/WorkDay ProgramsSheltered Workshop (SWS)Supported/Competitive Employment (SE)
(SE)
(SWS)
(SWS)
(SE)
Source: Braddock, D., State of the States in Developmental Disabilities, 2010, preliminary.
47
“I think we can do a ‘virtual nursing home’ with technology”…
Andy GroveCo-Founder, Intel Corp.
In USA Today, 2006
IIa: EMERGENCE OF SMART HOME TECHNOLOGIES
48
U.S. DEMAND FOR NEW I/DD RESIDENTIAL SERVICES IN THE NEXT DECADE IS 166,000
Source: Braddock, D., State of the States in Developmental Disabilities, 2010.
1980 1990 2000 2010 2020
Fiscal Year
0.0
300.0
600.0
900.0
Th
ou
san
ds
of
Per
son
s
259.9
345.2
440.2
607.1
772.76 or Fewer Person Settings7-15 Person SettingsPublic and Private 16 + Person Settings
Projected from 2000-2009
49
INTEGRATED WIRELESSSENSOR NETWORKS
IN THE FUTURE:
A combination of wireless cell phone, Internet, and sensor technology will connect people, objects, and events.
Smart homes/care will play key roles in assisted living for persons with I/DD, allowing seamless connectivity between clients, caregivers/health care providers, and parents.
50
WHERE TO PUT WIRELESS SENSORS?
TWO PRIMARY METHODS TO REMOTELY MONITOR A PERSON’S PHYSICAL AND MENTAL STATE AND LOCATION:
1. Via instrumenting the environment(Sensors located in rooms, on doorways, drawers, faucets, light switches, mattresses, pill bottles, etc.)
2. Via sensors located directly on people
Both have advantages: environmental sensors are less instrusive, and do not require user compliance. Person sensors offer more direct measurement.
51
MIT PLACELAB - BEHIND THE SCENES
Context-aware PDA with wireless sensors/motes
Source: MIT PlaceLab website at http://architecture.mit.edu/house_n/placelab.html
52
Source: Braddock, D., Coleman Institute, University of Colorado, 2010.
U.S. SMART HOME SERVICE PROVIDERS FOR PERSONS WITH ID
• IMAGINE!BOULDER AND LONGMONT COLORADO
• REST ASSURED, LLC., LAFAYETTE, INDIANA
• SOUND RESPONSE,MADISON, WISCONSIN
53
IMAGINE! SMART HOME, LONGMONT, CO, OPENED MAY 2010
Imagine! Smart Homes in Boulder and Longmont, Coloradohttp://www.imaginesmarthomes.org/
54
IMAGINE! SMART HOME, BOULDER, COLORADO: COMPLETED 2009
Imagine! Smart Homes in Boulder and Longmont, Coloradohttp://www.imaginesmarthomes.org/
55
• Private donations
• HUD
• Cities of Boulder and Longmont
• State of Colorado/Medicaid
FUNDING FOR HOMES
56
IMAGINE! SMART HOME, BOULDER, COLORADO: GREEN TECHNOLOGIES
Geothermal systems heat and cool the home
Photovoltaic cells generate electricity
57
• Employee/manager portal for centralized information collection and reporting
• Web-based medication prompt system
• Location based activity prompting/logging
• Web based training courses
• Lifelogging of resident histories
• Family portal for daily activities and health status with text and picture-sharing
STAFF SYSTEMS
IMAGINE! SMART HOMES, BOULDER/LONGMONT
58
• Accessible control of environment and appliances
• Accessible, safe kitchen and bathroom
• Cameras monitor high-risk areas
• Automated windows and doors
• Task prompters and reminders
• Specialized, accessible PC, Internet, journalingand web conferencing
CONSUMER, ENVIRONMENTAL AND COMMUNICATIONS ADAPTATIONS
IMAGINE! SMART HOMES, BOULDER/LONGMONT
59
• Activity and safety sensors are utilized: bio-metric, motion, pressure, contact, security, fire, temp, nurse call, door threshold.
• Residents’ badges provide location, call for assistance.
• Real-time resident monitoring, alerts, reporting and care planning.
ELITE CARE/CUROTEK WEB-BASED MONITORING SYSTEM
IMAGINE! SMART HOMES, BOULDER/LONGMONT
60
IMAGINE! SMART HOME ADAPTS ELITECARE WEB-BASED MONITORING SYSTEM
61
Creating Autonomy-Risk Equilibrium
• Infrared/RF tracking• Pendant Assistance calls• Bed weight, threshold, motion• Control lights, locks, appliances• Programmable events/alerts• Building sensors/controls• Real-time Intra/Intranet• DB Reports, trends, queries
www.elitecare.com
Oregon Assisted LivingOatfield EstatesJefferson Manor
Holistic care model
Open building design
Supportive technology
Elite Care Technologies CARE Systems
62
EliteCARE Copyright 2001
Assist resident Badge detects when resident
reaches his/her room Unlock their doors Turn lights on/off Turn ceiling fan on/off Disable unsafe appliances
Predict/prompt activity (future) Using statistical modeling
Source: Elite Care Corp.
SMART HOUSE BADGE
63
REST ASSURED PROGRAM
Staff person monitors several apartments simultaneously.
64
• Uses PTZ (Pan, Tilt, Zoom) cameras for monitoringin high risk areas like the kitchen
• Remote supervision via two-way audio/video communication with caregiver
• Motion, temperature, carbon monoxide, and door brake sensors used in, in addition to a Personal Emergency Response System
• Consumers report increased independence; caregiveris not a constant physical presence in the house
• Reduced overall cost of care
• Currently used primarily for third-shift support
Source: Jeff Darling, Executive Director, Rest Assured, Wabash, Indiana.
REST ASSURED PROGRAM
65
• Developed in collaboration with EPICS (Engineering Projects In Community Service) at Purdue University
• Serves consumers with ID
• 65 homes and apartments with136 consumers served
• Recent agreement with Humana to market technology to 500,000 elderly caregivers
Source: Jeff Darling, Executive Director, Rest Assured, Wabash, Indiana.
REST ASSURED PROGRAM–ATTRIBUTES
66
• Professional Monitors
• Communication between Monitor and staff/ individuals served
• Access to protocols and personal intervention strategies
• Provider agency back-up
• Individualized alarm readings
• Generates reports
SOUND RESPONSE SYSTEMS: MADISON
67
SENSORS
Personal Pagers Door/Window Security Sensors Smoke Detectors Carbon Monoxide Detectors Flood/Moisture Sensors Motion/Sound Sensors Stove Sensors Incontinent Detectors Other Sensors Available Upon Request
68
Completely Wireless in the Home Cellular Transmission- No Phone or Internet
Connection is Required 2-Way Communication Event Sequencing Data Tracking Portable and Adaptable to People’s
Homes and Abilities
EQUIPMENT FEATURES
Sound Response costs average between $25 to $850 per person per month
69
INDIANA GOVERNOR MITCH DANIELSENDORSES SMART HOME TECHNOLOGY
“We can alleviate some of the demand for Direct Support Professionals (DSPs) by identifying new service options for people who do not need intensive DSP support.
The system is tailored to the needs of each person who uses it and has been shown to improve personal independence, as well as alleviating the needs for a direct support professional where one is not needed.”
Mitch Daniels, Governor, State of IndianaThe Arc of Indiana, Meet the Candidates, Summer 2008
70
CURRENTLY HAS MEDICAID WAIVER AMENDMENT APPROVED BY CMS
• INDIANA
SUBMITTED WAIVER AMENDMENT, PENDING CMS APROVAL
• OHIO
OTHER STATES ARE IN THE PROCESS OF SUBMITTING WAIVER AMENDMENTS FOR TECHNOLOGIES TO CMS (E.G., FLORIDA, WEST VIRGINIA)
STATES WITH MEDICAID SUPPORT FOR SMART HOME TECHNOLOGIES
71
RECOMMENDATIONS:o Adopt early: learn from experienceo Start small: expand incrementallyo Adopt gradually: change care procedureso Assess needs, cost-benefits, & risk o Plan pilot & evaluation with R&D partner
o Source: Rodney Bell, Coleman Institute consultant (2007)
2000 2005 2010 2015
Care information systems … on web Predictive modeling COGNITIVE ASSISTANCE
EVOLUTION OF SMART HOME TECHNOLOGY
We are here
72
1. PDA Task Prompting Software
2. Adapted Web Browser
3. Adapted E-mail
4. Audio Books
5. Location Tracking
6. Personal Support Robots, Teaching Technologies
IIB. PERSONAL SUPPORT TECHNOLOGIES
73
PDA TASK PROMPTING SOFTWARE
Visual Assistant (Prompting System)
Source: Ablelink Technologies, Colorado Springs (Terry & Jonathan).
74
A pocket personal computer with an integrated PC-slot digital camera;
Staff/caretakers take pictures of—and narrate--the steps in a task;
SOURCE: Ablelink Technologies, Colorado Springs.
The verbal instructions and images guide users through the steps:
– Grocery shopping– Medications– Personal hygiene– Using public transportation, etc.
VISUAL ASSISTANT
75
Adapted Web Browser
The Web Trek adapted web browser improves access to the World Wide Web for people who have difficulty with reading and writing.
ADAPTED WEB BROWSER AND E-MAIL
SOURCE: Ablelink Technologies, Colorado Springs.
Adapted E-mail Program
76
Source: Ablelink Technologies, Colorado Springs; www.ablelinktech.com
ROCKET READER AUDIO BOOKS
77
LOCATION TRACKINGNextel mobile locator:
http://www.nextel.com/en/services/gps/mobile_locator
Wherifone:
http://www.wherify.com/wherifone/
Accutracking:
http://www.accutracking.com/
911 to go:
http://www.travelbygps.com/articles/tracking.php/
Contact your cell phone provider for phones/services
78
TREKKER BREEZE GPS
Verbally announces the names of streets, intersections and landmarks as you walk.
Source:http://
www.visabilitystore.org/browse.cfm/trekker-breeze-
gps/
79
INDOOR WAYFINDING SUPPORT
SOURCE: http://cognitivetech.washington.edu/assets2006_liu.pdf.
Participants preferred images with arrows, not audio alone
[In Development]
80
PERSONAL SUPPORT ROBOTS
Can serve as “life support partner” to follow a person from place to place, respond to commands, aid in activities of daily living, help with route finding, interact with others.
Source: Maja J Mataric, University of Southern California, Viterbi School of Engineering
81
Animated Teaching/Learning Tools Students choose animated images representing
themselves and their teacher.
Then students use the animated characters to engage in learning activities such as reading instruction.
Each of the 8 characters makes hundreds of emotions and expressions in real time.
For more information contact Sarel Van Vuuren at [email protected] http://ics.colorado.edu/
TEACHING TECHNOLOGIES
82
REHABILITATION ENGINEERING RESEARCH CENTER ONADVANCING COGNITIVE
TECHNOLOGIES (RERC-ACT)
University of Colorado – BoulderCathy Bodine, Ph.D., Principal Investigator
Co-funded by the Coleman Institute
University of Colorado School of Medicine - Anschutz
IIc. THE NEW CU RERC 2009-14
www.uchsc.edu/atp/RERC-ACT.html
83
RERC-ACT: THEMES IN 2010
1. EVALUATION AND TESTING OFEXISTING AND NEW TECHNOLOGIES
2. DEVELOPMENT OF GUIDELINESAND STANDARDS
3. CREATION OF A PLATFORM FORDEVELOPING A VARIETY OFCOGNITIVE TECHNOLOGYAPPLICATIONS AND PRODUCTS
84
RERC-ACT: 2010 COLLABORATORS
UNIVERSITIES• UNIVERSITY OF COLORADO/ANSCHUTZ AND BOULDER
• GEORGIA INSTITUTE OF TECHNOLOGY
• UNIVERSITY OF MARYLAND-BALTIMORE
• UNIVERSITY OF TORONTO
COMPANIES• IBM, HUMAN ABILITY AND ACCESSIBILITY CTR.
• ASSISTIVE TECHNOLOGY INDUSTRY ASSN.
• BENEFICIAL DESIGNS, INC.
• PEARSON KNOWLEDGE TECHNOLOGIES
• NEURINTEL, LLC
85
RERC-ACT: 2010 DEVELOPMENT PROJECTS
D1. Uniform standards for cognitive technologies
D2. Interactive animated agents platform for home, school, work and community
D3. Non-linear context-aware prompting for adults with cognitive disabilities in the workplace
D4. Mobile life coach vocational applications
D5. Socially interactive early childhood robotics
D6. Inclusive collaboration technology for employment
86
RERC-ACT: 2010 RESEARCH PROJECTS
R1. THE RERC-ACT Product Testing Laboratory
R2. Context-aware prompting system
R3. Mobile-based job-coaching intervention
R4. Cognitive decline and recovery from work interruptions in the IT workforce
R5. Vocabulary development in mild cognitive impairments
R6. Socially assistive robotics for skills acquisition.
87
• Envisions systems with wearable or environmental sensors that infer a user’s context and cognitive state.
• Prompts, reminders, and other forms of automatic intervention.
• Tasks addressed include navigation, remediation of memory impairments, behavioral self-regulation, and monitoring and guidance in the performance of ADLs.
Henry KautzProfessor & Chair, Department of Computer Science
University of Rochester, January 2010
COGNITIVE ASSISTANCE FRONTIER
88
COMPUTATION AND ENGINEERING Artificial intelligence Human-computer interaction Pervasive computing Electrical & Biomedical Engineering
HEALTH-RELATED SCIENCES Gerontology, Neurology, Rehab Medicine Medical Informatics Psychology and Cognitive Science PT, OT, Nursing
COGNITIVE ASSISTANCE DISCIPLINES
89
III. ECONOMIC UNCERTAINTY IN THE STATES
90
91
The Onion, November 6th, 2010.
92
93
U.S. INDUSTRIAL CAPACTIY UTILIZATION COLLAPSES : 2008-2010
Source: Federal Reserve (2010). G.17 Industrial Production and Capacity Utilization for October 18, 2010.
2005 2006 2007 2008 2009 2010Fiscal Year
65%
70%
75%
80%
85%
Pe
rcen
t C
ha
ng
e B
y M
on
th
82%
68%
74%
FACTORIES, UTILITIES, MINES
94
STATE TAX REVENUES PLUNGE, 2008-09
Source: The Nelson A. Rockefeller Institute of Government, August 30, 2010.
2007 2008 2009 2010
YEAR
-20%
-15%
-10%
-5%
0%
5%
10%P
erc
en
t C
ha
ng
e
5.4%
-16.5%
2.2%
95
THREE U.S. RECESSIONS: 82-83, 02-04, 08-10
79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10Fiscal Year
-8%
-6%
-4%
-2%
0%
2%
4%
6%
8%
Per
cen
t R
eal C
han
ge
in G
ener
al F
un
d
3.5%
-3.7%
-2.4%
6.5%
0.7%
3.8%
-1.3%
-3.6%
-0.5%
0.3%
2.0%
4.0%
-1.0%
-6.7%-7.3%
Source: National Governors Association and National Association of State Budget Officers (2010)79-09 "actual" state expenditure; 2010 "estimated."
96
STATE BUDGET GAPS: FY 2010
State
Percent of 2010 State
General Fund State
Percent of 2010 State
General Fund State
Percent of 2010 State
General Fund
Arizona 65.0% Louisiana 27.8% Mississippi 19.3%California 52.8% Connecticut 27.0% Delaware 18.2%Nevada 46.8% North Carolina 26.2% New Mexico 18.2%Illinois 43.7% Hawaii 25.2% Michigan 15.8%New Jersey 40.0% Virginia 24.1% Kentucky 14.5%New York 38.8% Colorado 23.8% Ohio 13.9%Rhode Island 34.8% Alabama 23.7% District of Columbia 13.0%Kansas 33.9% Wisconsin 23.7% Tennessee 12.1%Oregon 32.4% Pennsylvania 23.6% Texas 10.7%Alaska 28.9% Minnesota 22.7% Indiana 10.6%Georgia 28.8% Missouri 22.7% Nebraska 9.2%New Hampshire 28.6% Iowa 22.6% Arkansas 9.1%Florida 28.5% Idaho 22.4% West Virginia 8.2%Oklahoma 28.4% Utah 22.1% South Dakota 4.3%Vermont 28.3% South Carolina 21.5% Wyoming 1.8%Maine 28.0% Massachusetts 20.4% Montana n/aWashington 27.9% Maryland 20.3% North Dakota n/a
TOTAL 29.2%Source : McNichol, Oliff, & Johnson, Center on Budget and Policy Priorities , July 15, 2010.
97
AGGREGATE STATE BUDGET GAPS 2002-12
Source: McNichol, Oliff, & Johnson, Center on Budget and Policy Priorities, July 15, 2010;McNichol & Lav (November 8, 2006).
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011(e.) 2012(e.)
Fiscal Year
($250)
($200)
($150)
($100)
($50)
$0
$50
Bill
ion
s o
f D
olla
rs ($40)
($75) ($80)
($45)
$1
($6)
($29)
($110)
($192)($180)
($120)Last Recession
2007-09 "Great Recession"
98
99
ECONOMIC MOMENTUM 1 IN THE STATES:TOP FIVE AND BOTTOM FIVE
U.S. RANK STATE INDEX
1 Texas 1.202 North Carolina 0.913 Alaska 0.684 Utah 0.655 Oklahoma 0.65
46 Maine -0.7447 Connecticut -0.7648 Michigan -0.8449 Rhode Island -1.0750 Nevada -1.93
UNITED STATES 0.001Weighted average growth in personal income, employment and population (Federal Funds Information for States, September, 2010).
100
STATE BOND RATINGS: JANUARY 2010
Delaware AAA Alaska AA+ Alabama AA Arizona AA-
Florida AAA Kansas AA+ Arkansas AA Kentucky AA-Georgia AAA Nebraska AA+ Colorado AA Louisiana AA-Indiana AAA Nevada AA+ Connecticut AA Michigan AA-
Iowa AAA New Mexico AA+ Hawaii AA
Maryland AAA North Dakota AA+ Idaho AA
Minnesota AAA Ohio AA+ Maine AA Illinois A+Missouri AAA Oklahoma AA+ Massachusetts AA California A-
North Carolina AAA South Carolina AA+ Mississippi AAUtah AAA Tennessee AA+ Montana AAVirginia AAA Texas AA+ New Hampshire AA
Vermont AA+ New Jersey AAWashington AA+ New York AA
Wyoming AA+ Oregon AA
Pennsylvania AA
Rhode Island AA Chile A+South Dakota AA China A+West Virginia AA Italy A+Wisconsin AA Portugal A+
Estonia A-Libya A-
Source: NY Times 2/3/10 Poland A-
SELECTED COUNTRIES
TIER 5
TIER 1 TIER 2 TIER 4TIER 3
Source: Standard & Poors Ratings, NY Times, 2/3/10
101
CHANGING POPULATION MIGRATIONIN THE STATES 2006-09
Source: Federal Funds Information for States (2009). State Policy Reports, Vol. 27, No. 21.
California (793,578)New York (639,918)Michigan (356,139)New Jersey (229,605)Illinois (229,524)
Texas 644,310North Carolina 373,278Arizona 298,480Georgia 298,235South Carolina 183,159
OUT-MIGRATION: TOP 5 STATES
IN-MIGRATION: TOP 5 STATES
102
AMERICA’S TAX BURDEN IS AMONG THE SMALLEST IN THE DEVELOPED WORLD
Organisation for Economic Co-operation and Development (OECD). (2008, preliminary).
Tax burden: Personal income, employee and employer social security contributions, and payroll taxes as a % of GDP (households of married couples, two children).
Turkey 42.7% Czech Republic 27.1%Sweden 42.4% United Kingdom 27.1%Poland 42.1% Portugal 26.6%France 41.7% Japan 24.9%Belgium 40.3% Slovak Republic 23.2%Hungary 39.9% Canada 21.5%Greece 39.2% Switzerland 18.6%Finland 38.4% Mexico 18.2%Germany 35.7% Korea 16.2%Austria 35.5% Australia 16.0%Italy 35.2% New Zealand 14.5%Spain 33.4% Luxembourg 12.2%Denmark 29.6% UNITED STATES 11.9%Norway 29.6% Iceland 11.0%Netherlands 29.1% Ireland 8.1%
103
What To Do? Galbraith’s Guidance
“…we could begin to develop a society in which our work, our cultural accomplishments, social life, sense of fairness, the general standard for the whole population, your work with helping people who come into society with disabilities and impairments, these things become the true and dominant measure of how well we’re doing….”
James GalbraithUniversity of Texas Economist and Professor of Government
At the Coleman Conference, November 5, 2009.
104
FROM (GDP) PRODUCTION TO WELL-BEING
…the time is ripe for our measurement system to shift emphasis from measuring economic production [GDP] to measuring people’s well-being….
Stiglitz, Sen, & Fitoussi, Report by the Commission on the Measurement of Economic Performance and Social Progress, 2010, p. 12.
[www.stiglitz-sen-fitoussi.fr]
105
BERNANKE: NATION MUST TAKE ACTION SOON TO SHAPE FISCAL FUTURE
“The arithmetic is, unfortunately, quite clear…To avoid large and unsustainable budget deficits, the nation will ultimately have to choose among higher taxes, modifications to entitlement programs such as Social Security and Medicare, less spending on everything else from education to defense, or some combination of the above.
These choices are difficult, and it always seems easier to put them off—until the day they cannot be put off any more.”
NY Times, April 8, 2010.
106
STATES OUT OF BALANCE
“….There is no way that these newly elected Republican lawmakers and governors can follow through on their promises to erase huge deficits without raising taxes—except by making irresponsibly draconian cuts in the critical state services, particularly for the poor [including people with disabilities] and for education.
The states, like the federal government, need to get control of spending. That may mean dealing with out-of-control pensions. It may mean careful cuts in services combined with, yes, higher taxes.
NY Times, November 10, 2010.
107
STATES OUT OF BALANCE:II
States have long been in the paradoxical position of being closer to the lives of voters than the federal government, while receiving far less scrutiny and attention. But if Republicans begin abusing the privilege they have been handed, imposing unconscionable cuts and claiming an unfair partisan advantage, they may find the public’s outrage turning back on them in a hurry.
NY Times, November 10, 2010.
108
CONTACT INFORMATION
David Braddock, Ph.D.Associate Vice President, University of Colorado Coleman-Turner Chair/Professor in Psychiatry
Executive DirectorColeman Institute for Cognitive Disabilities (SYS 586)
3825 Iris Avenue, Suite 200Boulder, CO 80301
Financial support from the US Administration on Developmental Disabilities,& State DD agency assistance in data collection,
is gratefully acknowledged. Data provided in this presentation are preliminary. Your feedback is
welcomed.