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Revision 10-0; Effective June 1, 2010
A Historical Overview of Service and Supports for Individuals with Intellectual or Developmental Disabilities
Prior to 1960, the prominent model for providing services to individuals with intellectual or developmental disabilities (IDDs) was a medical model with services typically provided in an institutional setting. In the 1960s, a paradigm shift began that resulted in the development of other models of service delivery. In particular, Congress began to provide funds to states to begin developing services in community settings for the first time. Texas established community mental health and IDD centers in tandem with these changes in federal funding and expectations.
By the 1970s the federal government developed regulations and standards for treatment of individuals with intellectual or developmental disabilities who lived in institutions, which included requirements for developing Individual Program Plans (IPPs). These regulations and standards marked the shift from what was largely “custodial care” to a system that promoted “active treatment.” Active treatment, while still requiring that basic care needs be met, is notably different from custodial care by emphasizing the teaching of new skills to individuals with intellectual or developmental disabilities. Active treatment guidelines also required the individual to participate in the interdisciplinary team (IDT) that develops the individual’s IPP.
Following the adoption of the active treatment model, professionals and other stakeholders in the field began developing tools and resources to facilitate person-centered planning. The ultimate outcome of person-centered planning is to further improve the quality of life for people with disabilities. Person-centered planning represented a fundamental shift from service planning that required providers to keep people with disabilities safe to a service planning and service delivery system that provides supports necessary for individuals to achieve their desired outcomes.
In the 1980s the U.S. Health Care Financing Administration (HCFA), now the Centers for Medicare & Medicaid Services (CMS), started granting waivers from the existing Medicaid rules. Waivers allow states the flexibility to design alternatives to institutional services, including the option for states to provide services in community settings as an alternative to institutional settings. In 1985 the Home and Community-based Services (HCS) waiver program was developed by Texas to waive the requirements of intermediate care facilities for individuals with an intellectual disability or related conditions (ICF/IID) services. HCS allows flexibility in the development of services for individuals who have intellectual and developmental disabilities that choose to receive their services in the community instead of an institutional setting. The federal government requires HCS be cost-effective and to include safeguards to protect participants’ health and safety.
Current and Future Direction
Today we strive to support individuals with intellectual and developmental disabilities in achieving their desired lifestyles and in becoming valued members of the community by:
- addressing health and safety issues in the context of their desired lifestyles;
- offering opportunities to better achieve their goals; and
- making the most efficient use of all available resources to accomplish these goals.
Thus, waiver services are shifting from prescribing service delivery to outlining minimum requirements that must be met when designing services to support people to achieve the lifestyles they desire. Developing services that capture what is important to and for individuals who receive HCS services, as well as balancing choice and protection of health and safety, is a challenge for the service delivery system.
The Department of Aging and Disability Services (DADS) uses the term person-directed planning instead of person-centered planning to talk about the ongoing planning process that helps to determine an individual’s life path. Person-directed planning ensures it is the individual who is directing the process.
DADS supports the expectation that every individual should have the opportunity to participate in the community, gain and maintain relationships of their choosing, express preferences, make choices, fulfill goals, and live with dignity and respect. Person-directed planning is used to represent an individual and their family’s vision about how the person wishes to live, including aspirations for the future. Person-directed planning challenges DADS, HCS providers and Local Authorities (LAs) to work in cooperation to provide meaningful services and supports for the individuals who receive services.
Person-Directed Planning in the Home and Community-based Services Waiver Program
The LA service coordinator (SC) uses a person-directed planning process to gather information necessary to develop a Person-Directed Plan (PDP) that accurately reflects the individual’s goals and desires. The PDP is a written plan developed for an applicant or individual in accordance with Form 8665, HCS Person-Directed Plan, and Appendix IV, Discovery Tool. It describes the supports and services necessary to preserve the applicant’s or individual’s health and safety, and to achieve the desired outcomes identified by the applicant or individual or legally authorized representative (LAR) on behalf of the applicant or individual. The person-directed planning process:
- empowers the individual/LAR on behalf of the individual to direct the development of the plan of services and supports that meets the individual’s personal outcomes;
- identifies existing supports and services necessary to achieve the individual’s desired outcomes;
- identifies natural supports available to the individual and negotiates needed service system supports;
- occurs with the support of a group of people chosen by the individual (and LAR on the individual’s behalf); and
- accommodates the individual’s style of interaction and preferences regarding time and setting.
The SC, using the PDP Discovery Tool as a basis for information gathering, conducts interviews with the individual, LAR, provider staff or others who know the person well. The results of these information-gathering interviews are compiled to:
- prioritize what outcomes and needs are included on the PDP; and
- identify which outcomes and needs will be met through waiver services and which will be met through non-waiver services.
The individual, SC and the HCS provider develop the Individual Plan of Care (IPC) based on the PDP. The provider is then responsible for developing an Implementation Plan (IP) with the individual and LAR. The IP is a written document developed for each HCS Program service on the individual’s IPC not provided through the Consumer Directed Services option that identifies how HCS services will be implemented to accomplish the outcomes identified in the PDP.
The SC is expected to implement an ongoing person-directed planning process, not a single event planning process. In order to accomplish that, the SC will need to monitor and update the PDP as preferences or needs change and additional information is learned about the individual. When an individual’s preferences or needs change or additional information is discovered, the SC will notify the HCS provider and submit a copy of the HCS Person-Directed Plan Outcome Summary (Page 10 of Form 8665) that will identify the desired addition/change/deletion based on the individual’s preferences/needs. The program provider may then have to revise the IP(s) and/or IPC.
The system must be flexible enough to keep up with the current needs and wishes of the individuals who receive HCS services.
The desired outcome of the HCS service delivery model is to promote services and supports that contribute to the acquisition of meaningful outcomes for each individual. The success of this model depends on the individuals who receive HCS services, their LARs and family members, the program provider, the service coordinator and DADS.