The Connecticut General Assembly
OFFICE OF LEGISLATIVE RESEARCH
July 15, 1994 94-R-0670
TO:
FROM: John Kasprak, Senior Attorney
RE: Trends in Residential Services for the Mentally Retarded
You asked for information on trends in other states concerning residential services for people with mental retardation, particularly the issue of closing state institutions and moving people to smaller, community-based settings. You are interested in the range of alternatives being utilized. (The literature refers to institutions and other residential placements for those with developmental disabilities which includes people with mental retardation.)
SUMMARY
Nationally, the number of resident with developmental disabilities in state institutions has declined from 195,000 in 1967 to about 85,000 as of early 1993 and is projected to decline to an estimated 55,000 by the year 2000. The national reduction in institutional populations is closely associated with the development of community-based service systems (see" Residential Services for People with Developmental Disabilities," Report 93-1, State of Washington, January 14, 1993, p. 35). (Developmental Disabilities (DD) include mental retardation (cognitive impairment), epilepsy, spina bifida, cerebral palsy, autism, and other conditions.)
Since 1970, approximately 35 state institutions have closed in 20 states, and at least 15 more are scheduled to close by 1995. The state of New Hampshire closed its only state institution for the developmentally disabled in 1991, as did the District of Columbia. In New Hampshire, all individuals regardless of the severity of their disability are supported by the community. A few other states are in the process of building up their community systems and are expected to close their state institutions completely within the next two or three years. New York has closed more than half of its facilities since 1987 and plans to close the remainder by the year 2000. Vermont recently closed its state institution, Rhode Island closed its Ladd Center in March 1994 and Michigan plans to close its remaining three institutions this year (see "Community Living for the Developmentally Disabled," National Conference of State Legislatures, State Legislative Report, Vol. 18, No. 12, December 1993).
States are using three primary federal programs to help pay for community living services for people with developmental disabilities. These are the Home and Community-Based Waiver (HCB) program, the Community Supported Living Arrangement (CSLA) Program, and Targeted Care Management.
Internationally, the province of Ontario in Canada reduced its institutional population from over 8,000 to about 5,000 from 1975-87. (See "Survey of Community Adjustment of Previously Institutionalized Developmentally Disabled Persons," Canadian Journal of Psychiatry, December 1993, p.641).
STATE TRENDS
Following is more specific information on the "downsizing" of state institutions for people with developmental disabilities in 15 other states. (This information was compiled by Washington state and appears in their previously cited January 1993 report.) These 15 states are not necessarily a representative sample of the nation, caution the report's authors, because there was no clear selection criteria. But these states were selected because "they appear to have either generally "progressive" DD systems, innovative specific programs, or other features worth exploring" (Washington report, p.33) These states also apparently are balanced in terms of the percentage of DD funding devoted to institutional or community services.
Table 1 following provides data on state institutions and their residents in the selected states.
Table 1
State Institutions for the
Developmentally Disabled
Selected States (1992)
No. of Residents per
State DD No. of 100,000 State
State Institutions Residents Population
New Hampshire 0 0 0.0
Michigan 3 550 5.9
Colorado 3 376 8.4
Rhode Island 1 133 13.3
Oregon 2 528 18.6
Maryland 5 964 20.2
Kentucky 3 770 20.9
Table 1 Continued
No. of Residents per
State DD No. of 100,000 State
State Institutions Residents Population
Ohio 13 2,294 21.1
Minnesota 7 997 22.8
North Dakota 1 173 27.1
Missouri 5 1,433 28.0
Washington 6 1,482 30.4
Kansas 3 912 36.8
Texas 13 6,538 38.5
North Carolina 5 2,572 38.8
TOTAL 65 17,050 23.9
Source: "Residential Services for People with Developmental Disabilities," State of Washington, Report 93-1, January-1993, p. 34.
Colorado
Colorado has undergone major downsizing of its state institutions. It has three small institutions (one with no residents on campus) limited to those hardest to serve. State policy, as found in statute, calls for the least restrictive alternative for an individual and states a preference for community services. Admission to an institution requires a court order.
Kansas
Kansas closed one institution in 1988. A five year legislative plan calls for the closing of another institution. The governor apparently disagrees with this.
The state's Community Integration Demonstration Project has used the principles of supported living to assist 80 former institutional residents to live in the community. These individuals were representatives of all people served in Kansas facilities in terms of the nature and severity of their disabilities.
Kentucky
Kentucky has not experience any downsizing of its state institutions. A state agency proposed to close one of the state's three institutions but this was defeated by the legislature. Admission to an institution requires a court order. Terms of the mental retardation involuntary commitment statute have been in litigation.
Maryland
Downsizing has occurred in the state and there may be a consolidation of some of the five state institutions. Pressure to downsize has come from a parent's lawsuit and the Department of Justice. In 1991, Maryland's legislature enacted Community Supported Living Arrangement legislation. It covers all types of supported living services, including those provided under the Medicaid CSLA program, through the Home and Community Based waiver program, and those funded solely by the state. The legislation directs that those receiving CSLA services receive services from providers of their own choosing, live in homes they choose, and receive services tailored to their needs.
Many state institutions have closed in Michigan and some of the remaining three will probably close. The governor is committed to privatization. The state policy is that of placing the individual in the least restrictive alternative, with a preference for in-home and community placements.
Minnesota
Since 1980, Minnesota has moved 1,600 individuals from institutions, including 400 since 1989. State policy is to place a person in the least restrictive alternative. A 1990 state law provides that moving an institutional resident to the community is subject to appropriations. Additionally, admission to an institution requires a court order and review.
Missouri
Since 1988, Missouri has moved about 500 individuals from its state institutions. State policy calls for placing clients in the least restrictive setting. Admission to DD institutions are limited to criminal cases, and a few intensive medical and behavior cases.
New Hampshire
New Hampshire has a total community-based system having closed its one DD state institution in 1991. State policy is for people with DD to live in the least restrictive setting, with in-home considered better than out-of-home placements.
The state contracts with 12 area Agencies for Developmental Services, which are private, nonprofit corporations governed by citizen boards. Area agencies either provide direct services or contract for services, depending on local needs and resources. The local agencies must be redesignated every four years, which involves public participation and comment.
North Carolina
North Carolina has experienced minor downsizing of its state institutions. Exits from such settings have been partially offset by entries.
North Dakota
This state has moved 1,000 individuals from institutions over a 12-year period to comply with a court order (lawsuit brought by association of retarded citizens). State policy calls for living in the least restrictive appropriate setting.
North Dakota's supported living program serves over 600 individuals, aiming to bring services and supports to people who live in community living arrangements. Supported living services in the state are financed principally through the state's HCB waiver program.
Ohio
In Ohio, one institution out of 13 is closing. A closure plan announced in 1989 led to significant controversy. The institution lost Medicaid certification and the state decided to close it. A lawsuit challenging the closure was unsuccessful.
Oregon
The state has moved 1,300 individuals from the two state institutions since 1984 under pressure from the federal Health Care Financing Administration and the Department of Justice. State policy calls for living in the least restrictive environment. The community living system is considered primary, with state institutions as back-up facilities.
Rhode Island
The state's policy is to develop the community system, making institutions unnecessary. The state's one DD institution, which at its maximum served 1,200 people, closed in March of this year. In 1992, 140 individuals were moved from institutional to community settings.
Texas
Two of the state's 13 institutions are scheduled to close and the state is pursuing a gradual downsizing of its institutions. A federal lawsuit triggered the downsizing.
Washington
The state of Washington has moved 275 individuals from its state institutions since late 1989. The state is experiencing a large expansion of community placements. A significant number of developmentally disabled persons have moved from intermediate care facilities for the mentally retarded and nursing homes to community settings.
FEDERAL PROGRAMS
There are three primary federal programs that states are using to help pay for community living services for people with developmental disabilities. In 1993, 48 states were operating over 80 distinct Medicaid home and community-based (HCB) waiver programs for people with developmental disabilities. The Medicaid HCB waiver program allows a state to redirect Medicaid money that would be spent on institutional services to support a wide array of community services and supports. These include personal care/assistance, supported living, home modifications, skills building, and specialized equipment or assistive technology to help people live in the community. Such services are furnished in family homes, peoples' own homes or apartments, and specialized facilities.
Community Supported Living Arrangements (CSLA) services, added to the Medicaid program in 1990, are designed to promote community living and participation for people with developmental disabilities. CSLA services include personal assistance, training and habilitation, assistive technology, housing modifications, and other services to help a person take greater command of his live and take part in community activities. This program is on “pilot” status until 1994. As of the end of 1993, only California, Colorado, Florida, Illinois, Maryland, Michigan, Rhode Island, and Wisconsin offered these services. The CSLA program has less stringent eligibility criteria than the HCB waiver program (see NCSL Report, p. 3-4).
Finally, in more than half the states, Medicaid money pays for case management or service coordination for people with developmental disabilities through “targeted care management services.” Basically, service coordinators work with individuals and families to help identify the services that will help the person to live in the community.
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