david braddock keynote address nasddds 2010 annual conference

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


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


(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


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



-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



-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


-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


*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


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


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


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?


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?


• 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


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)


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*


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


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


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


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


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


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


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


35

STATES REPORT CONTINUING GROWTH IN FAMILIES SUPPORTED: 1988-2009


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


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


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


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


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


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


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)


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


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


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

91

The Onion, November 6th, 2010.

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


General Fund 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"

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.