Olmstead Plan Chronology

Department of Administration Governor's Council on Developmental Disabilities
July 1, 2019

2018

Planned "strategic review" of the Olmstead Plan (to review the results of Quality of Life Survey, achievements under measurable goals, and feedback from people with disabilities, families, providers, counties, counties and tribal governments, and state agencies) in establishing annual targets for measurable goals for subsequent periods. This strategic review may also indicate that some goals should be replaced because they are not the most effective measure and/or that goals need to be added.

January 29, 2018

The comprehensive plan for prevention of abuse and neglect of people with disabilities report was accepted by the Subcabinet. This plan outlined promising actions that could be taken before abuse and neglect occurs. The Specialty Committee, created by the Subcabinet in 2016 after the addition of a goal to the Olmstead Plan to develop a comprehensive plan to educate people with disabilities, their families, and the public on how to identify and report abuse and neglect and to develop a comprehensive prevention plan, developed eight major recommendations:

Create primary prevention strategies that focus on removing the causes of abuse and neglect before it happens.
Provide education that focuses on ensuring people with disabilities have the knowledge and skills necessary to exercise their rights to protect themselves from abuse and neglect.
Provide education for family members and supporters on the importance of autonomy and self-choice for people with disabilities in reducing the individual's risk of abuse and neglect.
Increase awareness and education of the general public on how to report suspected abuse and neglect and where to access services and support for survivors.
Educate disability service providers, adult and child protection agencies, criminal justice systems, health care providers and others on the incidence of abuse and neglect, effective response models, and each other's roles in the system.
Prevent re-victimization by treating the immediate needs of victims and creating a system of accountability to stop perpetrators from re-offending.
Complete routine data analysis to identify priority areas to target long term prevention strategies, reduce abuse and neglect, promote healing, and prevent re-offending.
This comprehensive prevention plan, when fully implemented, aims to reduce the likelihood of abuse occurring, and when it does occur, people with disabilities will receive timely and effective response, protection, and support. The plan builds on Olmstead Plan efforts to elevate the status of people with disabilities in our society by ensuring that they are leaders and partners in the state's comprehensive abuse and neglect prevention efforts.

Additionally, during the Olmstead Subcabinet meeting, an interest in numbers for the universe of individuals who may be affected by the work related to the measurable goals was expressed. These numbers were intended to provide context, and can be interpreted as the total number of individuals who may be impacted by the related measurable goal. This information was planned for inclusion in the March 2018 Plan revision. For details on where these numbers would help provide context for a goal, and for the locations of current information on the goals, see page 19 of the January 29, 2018 Subcabinet meeting materials.

February 26, 2018

The Olmstead Subcabinet reviewed and approved the baseline and annual goals for two measurable goals:

Preventing abuse and neglect goal 3: From July 2015 to June 2016, there were 2,835 individuals who experienced a substantiated or inconclusive abuse or neglect episode. Of those individuals, 126 (4.4 percent) had a repeat episode of the same type of abuse or neglect within six months. The annual goals previously established can remain unchanged from the February 2017 Olmstead Plan.
Preventing abuse and neglect goal 4: From July 2013 to June 2016, there were 13 identified schools that had three or more investigations of alleged maltreatment of a student with a disability within the three preceding years. There were 66 students with a disability who were identified as alleged victims of maltreatment within those schools.

Proposed annual goals to reduce the number of identified schools that had three or more investigations of alleged maltreatment of a student with a disability within the three preceding years and the number of students with a disability who were identified as alleged victims of maltreatment within those schools:

By July 31, 2018, the number of identified schools and students will decrease by 10 percent from baseline.
By July 31, 2019, the number of identified schools and students will decrease by 25 percent from baseline.
By July 31, 2020, the number of identified schools and students will decrease by 50 percent from baseline.

The Community Engagement Workgroup charter was approved by the Olmstead Subcabinet. The Community Engagement Workgroup created strategies and activities to implement the Olmstead community engagement plan, making sure that engagement practices were person-centered, accessible, inclusive, transparent, and equitable for diverse communities.

Also, the quarterly report was approved by Olmstead Subcabinet, including data acquired through January 31, 2018. This report included progress toward goals related to:

Movement of people with disabilities from segregated to integrated settings (n = 576).
Movement of individuals from waiting lists.
Quality of Life measurement results (not available at the time of the report).
Increasing system capacity and options for integration.

Just over half of Olmstead Plan measurable goals (18 of 30) were met, on track to be met, or in process. Notable findings and planned responses included:

The June 30, 2018 goal to reduce the percentage of people awaiting discharge at AMRTC to 32 percent or less was not on track to be met. Ongoing efforts to improve progress toward this goal included collaboration between AMRTC and counties to aid in identifying more applicable community placements and resources for patients awaiting discharge as well as improvements in AMRTC's notification process for patients who no longer met hospital criteria of care to county partners and other key stakeholders to ensure that all parties involved were informed of changes in the patient's status and resources were allocated towards discharge planning.
The December 2017 goal to increase the average monthly number of individuals leaving MSH to a more integrated setting to eight or more was also not on track to be met. Ongoing efforts included collaboration with counties to identify individuals at MSH who had reached maximum benefit from treatment and to identify community providers and expand community capacity.
The June 30, 2017 goal to increase the percentage of individuals choosing to move to a more integrated setting who had a plan that adhered to transition protocols that met the principles of person-centered planning and informed choice to 50 percent was not on track to be met. Since July 2016, the lead agency review team made recommendations to each county visited on how to improve their person-centered practices. Counties were in varying stages on their person-centered journey. The recommendations encouraged lead agencies to set expectations for the quality and content of support plans as well as to seek out and provide training for their staff on providing person- centered practices. This could involve changes in agency practices as well as changes to how agencies work with their community partners. Beginning in January 2018, DHS required individual remediation when lead agencies did not comply with the person- centered protocols. When findings from a case file review indicated that files did not contain all required documentation, the agency would be required to bring all cases into full compliance by obtaining or correcting the documentation. All corrections needed to be made within 60 days of the lead agency review site visits. Corrective action plans would be required when patterns of non-compliance were evident. DHS conducted regional day-long training and technical assistance sessions with counties and tribes during May through September 2017. Due to high demand, DHS scheduled an additional five training sessions through February 2018. In total 15 training sessions were offered to lead agency staff across the state. A supervisor tool kit was being developed to support counties, tribes and contracted case management providers in the oversight of plan development according to the protocol. The expectation was that the number of plans that adhered to the protocols would increase over time and during 2018.
The March 1, 2017 goal to eliminate the DD waiver waiting list was not met. In addition to updating this goal to more accurately define success in the institutional exit and immediate need categories accessing waiver funding at a reasonable pace, DHS planned to work with lead agencies to continue to approve funding for persons according to the reasonable pace goals.
The June 30, 2018 goal to increase the percentage of plans for people using disability home- and community-based waiver services that met required protocols to 70 percent was not on track to be met. Since July 2016, the lead agency review team made recommendations to each county visited on how to improve their person-centered practices. Counties were in varying stages on their person-centered journey. The recommendations encouraged lead agencies to set expectations for the quality and content of support plans as well as to seek out and provide training for their staff on providing person-centered practices. This could involve changes in agency practices as well as changes to how agencies worked with their community partners. Beginning in January 2018, DHS required individual remediation when lead agencies did not comply with the person-centered review protocols. DHS conducted regional day-long training and technical assistance sessions with counties and tribes during May through September 2017. Due to high demand, DHS scheduled an additional five training sessions through February 2018. In total 15 training sessions were offered to lead agency staff across the state. A supervisor tool kit was being developed to support counties, tribes and contracted case management providers in the oversight of plan development according to the protocol. The expectation was that the number of plans that adhered to the protocols would increase over time and during 2018.
Neither the June 30, 2018 goals to reduce mechanical restraints to no more than 185 reports of mechanical restraint nor the goal to reduce the number of individuals approved for emergency use of mechanical restraint to 13 were on track to be met.
The June 30, 2017 goal to decrease the number of people who discontinued waiver services after a crisis (indicating they left community services and were likely in a more segregated setting) to no more than 45 people was not met. Given the small number of people identified in any given quarter as part of this measure, as of March 2017, DHS staff began conducting person-specific research to determine the circumstances and outcome of each identified waiver exit. This would enable DHS to better understand the reasons why people were exiting the waiver within 60 days of receiving a service related to a behavioral crisis and target efforts where needed most to achieve this goal.
The September 30, 2017 goal to increase the number of new individuals with disabilities working in competitive integrated employment to 2,969 was not met, though it was noted that this may have been related to acts that were passed (e.g., WIOA) and policies from Services for the Blind.
The June 30, 2017 goal to reduce the number of students experiencing emergency use of restrictive procedures by 80 students or 0.02 percent of the total number of students receiving special education services was not met. The MDE Restrictive Procedures Stakeholders Workgroup (2017 Workgroup) focused its attention on reducing the use of restrictive procedures, specifically to eliminate the use of seclusion. Districts were requesting more tools to avoid the need for restrictive procedures. The 2017 Workgroup and MDE made significant progress in implementation of the 2016 statewide plan. The 2017 Workgroup and MDE continued to work toward availability of mental health services across the state, and improving the capacity of school districts to provide professional development in support of progress toward this activity's annual goals.
The June 30, 2017 goal to increase the percentage of children who received children's mental health crisis services and remained in their community to 83 percent was not met, though there was an overall increase. DHS worked with mobile crisis teams to identify training opportunities that would help increase their capacity to address the complexities they were seeing and committed to providing trainings in identified areas specific to crisis response. It was anticipated that this would increase the teams' ability to work with individuals with complex conditions/situations effectively.
The June 30, 2017 goal to increase the percentage of adults who received adult mental health crisis services and remained in their community (e.g., home or other setting) to 60 percent was not met. DHS worked with mobile crisis teams to identify training opportunities that would help increase their capacity to address the complexities being seen and committed to providing trainings in identified areas specific to crisis response. It was anticipated that this would increase the teams' ability to work with more complex clients/situations effectively.

During their meeting, as part of the Olmstead Plan amendment process, the Olmstead Subcabinet reviewed a summary of the themes heard during the public input period. The public input period included public listening sessions, focus groups, and written input by email and through the website, yielding over 102 comments. Themes and agency responses can be found on page 87 of the February 26, 2018 Subcabinet meeting materials.

Second draft amendments to Olmstead Plan measurable goals were also created. This addendum included the draft potential amendments to Olmstead Plan measurable goals that were proposed by the Olmstead Subcabinet agencies after the first round of public comment. Changes focused on measurable goals in the following topic areas: transition services, community engagement, and preventing abuse and neglect.

March 19, 2018

A draft revision of the February 2017 Olmstead Plan was developed. Changes focused on timeliness of waiver funding and plan management oversight.

March 26, 2018

The Quality of Life Survey baseline report was accepted by the Olmstead Subcabinet after determining that the nonresponse bias weighting had no effect. The differences between this baseline survey and follow-up surveys will be used in the future to better understand whether increased community integration and self-determination occur for people with disabilities receiving services in selected settings. Key results included:

The survey measured participants' decision-making, as compared to what decisions paid staff made for them. This was scored 0 to 100 on the Decision Control Inventory (DCI). Minnesota's average DCI score was 66.2 out of 100.
Interviewers asked participants 14 questions, the answers to which were then calculated into an overall quality of life score. Minnesota's baseline quality of life score was 76.6 out of 100.
More than 800 participants reported some earnings, including wages or piecework. On average, participants earned $95 per week. Hourly earnings ranged from $3.30 to $7.60 depending on employment type.
Participants averaged 32 outings per month, which was lower than the general population (46 outings outside the house per month, not counting work).
Integration scores were highest for activities such as competitive employment, self- employment, volunteer work, and supported employment. In contrast, integration was lowest in day training and habilitation, sheltered employment or workshops, and adult day programs. This was consistent with other research. However, these scores indicated a higher level of potential segregation in certain community-based settings.
Relatives were the most commonly reported relationship type (46 percent), followed by staff of any type (26 percent), and other friends (22 percent).

During their meeting, the Olmstead Subcabinet also reviewed and accepted the report: Recommendations to Expand, Diversify and Improve Minnesota's Direct Care and Support Workforce. The recommendations were developed by the cross-agency direct care and support workforce working group. This report aimed to provide a set of clear and consistent strategic priorities for future action to address the growing crisis in the provision of direct care and support services in Minnesota. If implemented, the actions could produce meaningful progress toward alleviating the direct care and support workforce shortage in Minnesota. To review the complete report, see page 135 of the March 26, 2018 Subcabinet meeting materials. Major recommendations included:

Increasing worker wages and/or benefits.
Expansion of the worker pool.
Improving the workforce by enhancing training for direct care and support professionals.
Increasing job satisfaction (including quality of the job).
Raising public awareness by promoting direct care and support careers.
Promoting service innovation.
Enhancing data collection.

March 29, 2018

Annual amendment to Olmstead Plan, which included 38 measurable goals. Updates focused on employment, transportation, and community engagement.

April 23, 2018

The Olmstead Subcabinet reviewed and approved updates to existing Qualify of Life workplans. For additional details on proposed changes, see page 13 of the April 23, 2018 Subcabinet meeting materials.

May 21, 2018

The quarterly report was reviewed by the Olmstead Subcabinet, including data acquired through April 30, 2018. This report included progress toward goals related to:

Movement of people with disabilities from segregated to integrated settings (n = 575).
Timeliness of waiver funding.
Quality of Life measurement results (see the Olmstead Plan Quality of Life baseline report for more details, which was presented at the March 26, 2018 Olmstead Subcabinet meeting).
Increasing system capacity and options for integration.

This was the first quarterly report to include universe numbers when available. The universe number is the total number of individuals potentially impacted by the goal. This number provides context as it relates to the measure. The majority of Olmstead Plan Measurable goals (10 of 13) were on track to be met, or in process. Notable findings and planned responses included:

The June 20, 2018 goal to reduce the percentage of people at AMRTC awaiting discharge to 32 percent or less was not on track to be met. Ongoing efforts to improve progress toward this goal included collaboration between AMRTC and counties to aid in identifying more applicable community placements and resources for patients awaiting discharge as well as improvements in AMRTC's notification process for patients who no longer met hospital criteria of care to county partners and other key stakeholders to ensure that all parties involved were informed of changes in the patient's status and resources were allocated towards discharge planning.
The December 31, 2018 goal to increase the average monthly number of individuals leaving MSH to a more integrated setting to nine or more was not on track to be met. Ongoing efforts included continuation of expanded community capacity, as well as identification of individuals who could be served in more integrated settings. Legislation in 2017 increased the base funding for state operated facilities to improve clinical direction and support to direct care staff treating and managing clients with complex conditions, some of whom engage in aggressive behaviors. The funding will enhance the current staffing model to achieve a safe, secure and therapeutic treatment environment. Of the 65 additional funded positions, 45 full-time equivalents were filled as of April 13, 2018. These positions consisted primarily of direct care staff such as registered nurses, forensic support specialists and human services support specialists. The positions that remained to be filled were in professional areas such as psychologists, social workers, recreational and occupational therapists.
The June 30, 2018 goal to reduce reports of mechanical restraint to no more than 185 was not on track to be met.

The Olmstead Subcabinet also reviewed the Community Engagement Workgroup Charter/Membership, which was an updated charter for the 2018 Community Engagement Workgroup. Updates included members selected for the workgroup and updated workgroup goals. For details on the charter update, see page 49 of the May 21, 2018 Olmstead Subcabinet meeting materials.

June 22, 2018

The Olmstead Subcabinet reviewed legislative proposals related to the priorities in the Olmstead plan. Approved proposals included:

Through the Bonding Bill, MDE had $25 million approved for school safety grants, and a $5 million grant to the Southwest/West Central Service Center to create a rehab center in Cosmos, Minnesota.
The Minnesota Department of Human Rights (MDHR) was involved in legislation about misrepresentation of an animal as a service animal, which is now a misdemeanor.
DHS received close to $30 million in the bonding bill to establish regional crisis housing centers to deal with mental health crises.
Through the Bonding Bill, Minnesota Housing received $80 million in housing infrastructure bonds. These funds were heavily used in the last five years to provide permanent supportive housing of various types, to include units for people with disabilities. From the $80 million, $30 million will be for housing for people with behavioral health needs. Minnesota Housing will be working with DHS, counties and providers to define what that means.
Minnesota Housing also received $10 million in funds to renovate public housing throughout the state. This would be for basic repairs such as elevators, plumbing, roofs, and health and safety items. Low-income people with disabilities often live in public housing.

The contract with the Improve Group was finalized for the implementation of the Quality of Life survey, with the goal of re-surveying 500 individuals by the end of the year. Results from this survey are due for review by the Olmstead Subcabinet in December 2018.

Additionally, the Community Engagement Workgroup Charter was approved by the Olmstead Subcabinet.

The Olmstead Subcabinet also reviewed the Prevention of Abuse and Neglect Recommendations. The Olmstead Subcabinet also reviewed the Comprehensive Plan for Prevention of Abuse and Neglect of People with Disabilities report was accepted by the Subcabinet on January 29, 2018. That report outlined promising actions to prevent abuse and neglect for people with disabilities. The Subcabinet directed staff from DHS, MDH, MDE, and the Office of Ombudsman for Mental Health and Developmental Disabilities (OMHDD) to review the report and identify recommendations that could be implemented by adding and updating existing strategies and workplan action items. The Prevention of Abuse and Neglect Recommendations are the results of that review. The recommendations begin on page 19 of the June 22, 2018 Olmstead Subcabinet meeting materials.

July 23, 2018

Commissioner Tingerthal provided a brief summary of a recent status conference with the Court to the Olmstead Cabinet, including the following:

A status conference was held by the Court on July 12, 2018 on both Olmstead and the underlying Jensen litigation.

The Court was provided an update on Olmstead, including:

An update on actions taken since the last status conference in December 2017.
Notable areas of success and areas that need improvement, which incorporated data reported in the December 2017 annual report, and the February and May 2018 quarterly reports.
An update on the Quality of Life Baseline Survey and the next steps in that process.
An overview of the process used to revise the Olmstead Plan, adopted in March 2018.
The upcoming strategic review process.

The expectation was that there would be another status conference in six months.

The Olmstead Subcabinet also accepted the Direct Care/Support Workforce Report recommendations, which had been submitted for review in March 2018. This report laid out a strategic vision for tackling the crisis in the direct care and support workforce. The Cross- Agency Direct Care and Support Workforce Shortage Working Group identified seven prioritized recommendations, each which contained subordinate strategies. The Olmstead Subcabinet requested that the work group further review and edit the recommendations included in the report to:

Prioritize the direct care report recommendations for implementation.
Review and update the direct care report recommendations to identify:
- Which recommendations would need legislative action.
- Which recommendations would require state agency action.
- Which recommendations require collaborative community efforts.

The workgroup submitted Recommendations to Expand, Diversify, and Improve Minnesota's Direct Care and Support Workforce.

August 27, 2018

The Olmstead Subcabinet approved Transportation Goal 5, to be incorporated in the August 2018 quarterly report. This goal reads as follows:

By 2040, 100 percent of the target population will be served by regular route level of service for prescribed market areas 1, 2, and 3 in the seven county metropolitan area.
- Currently, the percent of the target population serviced by a regular route level of service for market area 1 is 95 percent, is 81 percent for market area 2, and is 67 percent for market area 3.
- An interim goal was also set for Transportation Goal 5: By 2025, the percentage of target population served by regular route level of service for each market area will be 100 percent for market area 1, 95 percent for market area 2, and 70 percent for market area 3.

For additional details Transportation Goal 5, see page 5 of the August 27, 2018 Olmstead Subcabinet meeting minutes and page 13 of the August 27, 2018 Olmstead Subcabinet meeting materials.

The quarterly report was also reviewed and approved by the Olmstead Subcabinet, including data acquired through July 31, 2018. This report included progress toward goals related to:

Movement of people with disabilities from segregated to integrated settings (n = 593).
Movement of individuals from waiting lists.
Quality of Life measurement results (not available at the time of the report).
Increasing system capacity and options for integration.

Just over half of Olmstead Plan measurable goals (14 of 21) were met, on track to be met, or in process. Notable successes included:

More individuals left ICF/DD programs to more integrated settings. During this quarter, 62 individuals left ICF/DD programs to more integrated settings. After two quarters, the total number was 104, which exceeded the annual goal of 72.
More individuals with disabilities under age 65 in a nursing facility longer than 90 days left for more integrated settings. During this quarter, 201 individuals moved from nursing facilities to more integrated settings. After two quarters, 54 percent of the annual goal of 750 had been achieved.
More individuals left other segregated settings to more integrated settings. During this quarter, 297 individuals moved from other segregated settings to more integrated settings. After two quarters, the total number was 595, which exceeded the annual goal of 500.
Planning for individuals experiencing a transition has improved over the last three quarters. Adherence to Transition Protocols improved from 52.2 percent to 68.2 percent and most recently to 88.2 percent.
The utilization of the Person Centered Protocols has improved over the last three quarters. Of the eight person centered elements measured in the protocols, performance on all elements improved over the 2017 baseline. Seven of the eight elements showed consistent progress, and four of the eight were at 90 percent or greater in this quarter.
There were fewer individuals waiting for access to a DD waiver. At the end of the current quarter there were 94 individuals who had funding approval pending compared to 237 people the same quarter last year.
The number of reports of use of emergency use of manual restraints was lower at 904 reports this quarter compared to 955 in the previous quarter.
The number of individuals approved for the emergency use of mechanical restraints at the end of the quarter was 13, which is on track to meet the annual goal of 13.
More students with Developmental Cognitive Disabilities (DCD), ages 19 – 21 entered into competitive integrated employment. During the last year, an additional 179 students entered into competitive integrated employment.
More students had active consideration of AT during their IEP team meetings. During the last year 94.9 percent had active consideration of AT.
More individuals with disabilities participated in Governor appointed Boards and Commissions and Olmstead Subcabinet workgroups. During the last year there were 197 individuals participating who self-identified as having a disability.
Measurable goals targeted for improvement and planned responses included:
The June 30, 2018 goal to decrease the percent of people at AMRTC who no longer meet hospital level of care and are currently awaiting discharge to the most integrated setting to 32 percent or less was not met. Ongoing efforts from previous quarters will continue to support improvements in progress toward this goal.
The December 31, 2018 goal to increase the number of individuals leaving the MSH to a more integrated setting to 9 or more was not on track to be met. Ongoing efforts from previous quarters will continue to support improvements in progress toward this goal. Additionally, increased funding for state operated facilities to improve clinical direction and support to direct care staff treating and managing clients with complex conditions, will enhance the current staffing model to achieve a safe, secure and therapeutic treatment environment.
The 2018 goal to reduce the emergency use of mechanical restraints with approved individuals to 185 or less reports was not on track to be met.
The June 30, 2018 goal to increase the percent of children who remain in the community after a mental health crisis to 85 percent was not on track to be met. DHS continues to work with mobile crisis teams to identify training opportunities for serving children in crisis, and to support the teams as they continue to support more children with complex conditions and living situations.
The June 30, 2018 goal to increase the percent of adults who remain in their community after a mental health crisis to 62 percent was not on track to be met. DHS continues to work with mobile crisis teams to identify training opportunities that would help increase their capacity to address the complexities they are seeing and has committed to providing trainings in identified areas specific to crisis response.

Additionally, Community Engagement Goal Two (by April 30, 2018, establish a baseline and annual goals) and Preventing Abuse and Neglect Two (by January 31, 2018, the number of emergency room visits and hospitalizations due to abuse and neglect will be reduced by 10 percent compared to baseline) will be modified during the Plan amendment process, as it was determined that measures were not available to gather reliable and valid data.

September 24, 2018

The Olmstead Subcabinet examined strategic review findings from the past three years, including progress made toward each goal in the Plan:

Eighteen goals were making progress toward achieving the overall goal on schedule. Nine had already achieved their overall goals.
Nine goals were progressing at some level but needed improvement.
Twenty goals were in process. "In process" means that there is either no verifiable data reported thus far or there is insufficient data to determine whether progress has been made. Twelve of these goals appeared to be moving in the right direction, two needed improvement, and six had not been reported yet.

The Subcabinet also discussed the development of a plain language version of the strategic review document. For additional details on the strategic review draft, see page 2 of the September 24, 2018 Olmstead Subcabinet meeting minutes and page 21 of the September 24, 2018 Olmstead Subcabinet meeting materials.

October 29, 2018

Draft workplans for the 2018–2019 Olmstead Plan were reviewed by the Olmstead Subcabinet. For additional details on the draft workplans, see page 3 of the October 29, 2018 Olmstead Subcabinet meeting minutes and page 27 of the October 29, 2018 Olmstead Subcabinet meeting materials.

November 26, 2018

During the Olmstead Subcabinet meeting, Commissioner Tingerthal announced that a recommendation was made to issue a new Executive Order, continuing the Olmstead Subcabinet under the new administration.

Additionally, the Subcabinet reviewed and approved the November quarterly report, including data acquired through October 31, 2018. This report included progress toward goals related to:

Movement of people with disabilities from segregated to integrated settings (n = 538).
Timeliness of waiver funding.
Quality of Life measurement results (not available at the time of the report).
Increasing system capacity and options for integration.

Two-thirds of Olmstead Plan measurable goals (18 of 27) were met, on track to be met, or in process. Notable successes included:

During this quarter, 36 individuals left ICF/DD programs for more integrated settings. After three quarters, the number was 140, which exceeded the annual goal of 72. (Transition Services Goal One A)
During this quarter, 195 individuals with disabilities under age 65 in a nursing facility longer than 90 days moved to more integrated settings. After three quarters, 79% of the annual goal had been achieved. (Transition Services Goal One B)
During this quarter, 272 individuals moved from other segregated settings to more integrated settings. After three quarters, the total number was 867, which exceeded the annual goal of 500. (Transition Services Goal One C)
Planning for individuals experiencing a transition improved through adherence to Transition Protocols. Performance during this quarter was at 88.5% compliance. (Transition Services Goal Four)
The utilization of the Person-Centered Protocols improved over the last four quarters. Of the eight person-centered elements measured in the protocols, performance on all elements improved over the 2017 baseline. Four of the eight elements showed progress over the previous quarter, and three of the eight were at 90% or greater in this quarter. (Person-Centered Planning Goal One)
There were fewer individuals waiting for access to a DD waiver. At the end of the quarter 73% of individuals were approved for funding within 45 days. Another 20% had funding approved after 45 days.
The number of individuals experiencing a restrictive procedure was lower, at 644 individuals in 2018 compared to 692 in 2017. (Positive Supports Goal One)
The number of reports of emergency use of manual restraints was lower, at 843 reports this quarter compared to 904 in the previous quarter. (Positive Supports Goal Two)
The number of individuals approved for the emergency use of mechanical restraints at the end of the quarter was 13, which met the annual goal of 13. (Positive Supports Goal Three B) The number of individuals in competitive integrated employment increased by 814 in the past year. (Employment Goal Two)
The number of women with disabilities and/or serious mental illness who had a cervical cancer screening was 27,270, which was an increase of 5,877 over baseline. (Health Care and Health Living Goal One)
The number of children and adults with disabilities who had an annual dental visit was 33,746 over baseline. (Health Care and Healthy Living Goal Two)
The percentage of people receiving community services within 30 days after discharge from the hospital was 94.1% and exceeded the annual goal of 91%. (Crisis Services Goal Four B)
The percentage of people receiving crisis services within ten days of referral was 88.9%. This exceeded the annual goal of 87%. (Crisis Services Goal Five)

Measurable goals targeted for improvement and planned responses included:

Transition Services Goal Two, to decrease the percentage of people at AMRTC who no longer meet hospital level of care and are currently awaiting discharge to the most integrated setting to ≤ 30% by June 30, 2019.
- AMRTC continues to serve a large number of individuals who no longer need hospital level of care, including those who need competency restoration services prior to discharge. The percentage of patients hospitalized at AMRTC who are civilly committed after being found incompetent continues to increase and was around 75% at the time of this report. The percentage of patients hospitalized at AMRTC who are under only mental health commitment was around 25%. With the continued decrease in the number of patients hospitalized at AMRTC under only mental health commitments, every patient not needing hospital level of care had greater impact on the overall percentage.
- During the last year there was a higher percentage of individuals awaiting discharge for those under mental health commitment (50.9%) than for those who were civilly committed to AMRTC after being found incompetent (27.7%). However, the percentage of patients hospitalized at AMRTC who were civilly committed after being found incompetent continued to increase and was around 75% at the time of this report. Individuals under mental health commitment have more complex mental health and behavioral support needs. When they move to the community, they may require 24- hour-per-day staffing or 1:1 or 2:1 staffing. Common barriers that can result in delayed discharges for those at AMRTC include a lack of housing vacancies and housing providers no longer accepting applications for waiting lists.
- Community providers often lack capacity to serve individuals who exhibit these behaviors:
  - Violent or aggressive behavior (i.e., hitting others, property destruction, past criminal acts);
  - Predatory or sexually inappropriate behavior;
  - High risk for self-injury (i.e., swallowing objects, suicide attempts); and
  - Unwillingness to take medication in the community.
- Ongoing efforts are facilitated to improve the discharge planning process for those served at AMRTC:
  - Improvements in the treatment and discharge planning process to better facilitate collaboration with county partners: AMRTC increased collaboration efforts to foster participation with county partners to aid in identifying more applicable community placements and resources for individuals awaiting discharge.
  - Improvements in AMRTC's notification process for individuals who no longer meet hospital criteria of care to county partners and other key stakeholders to ensure that all parties involved are informed of changes in the individual's status and resources are allocated toward discharge planning.
  - Improvements in AMRTC's notification process to courts and parties in criminal cases for individuals who were civilly committed after a finding of incompetency who no longer meet hospital criteria of care.
- In order to meet timely discharge, individual treatment planning is necessary for individuals under mental health commitment who no longer need hospital level of care. This can involve the development of living situations tailored to meet their individualized needs, which can be a very lengthy process. AMRTC continued to collaborate with county partners to identify, expand, and develop integrated community settings.
- DHS convened a cross-division, cross-administration working group to improve the timely discharge of individuals at MSH and AMRTC to identify barriers, current and future strategies, and any needed efficiencies that could be developed between AMRTC and MSH to support movement to the community. Counties and community providers will be consulted and engaged in this effort as well. Annual reporting to the Olmstead Subcabinet on the status of these efforts was scheduled to begin by December 31, 2018.
Transition Services Goal Three, to increase the number of individuals leaving the MSH for a more integrated setting to 10 per month by December 31, 2019.

Legislation in 2017 increased the base funding for state-operated facilities to improve clinical direction and support to direct care staff treating and managing clients with complex conditions, some of whom engage in aggressive behaviors. The funding will enhance the current staffing model to achieve a safe, secure, and therapeutic treatment environment. These positions are primarily in direct care positions such as registered nurses, forensic support specialists, and human services support specialists. As of September 2018, 97% of professional positions were filled and 96.2% of direct care positions were filled.
One identified barrier for MI&D committed and Other committed is the limited number of providers with the capacity to serve:
- Individuals with Level 3 predatory offender designation;
- Individuals over the age of 65 who require either adult foster care, skilled nursing, or nursing home level care;
- Individuals with DD/ID with high behavioral acuity;
- Individuals who are undocumented; and
- Individuals whose county case management staff has refused or failed to adequately participate in developing an appropriate provisional discharge plan for the individual.
Some barriers to discharge identified by the Special Review Board (SRB) in their 2017 MI&D Treatment Barriers Report as required by Minnesota Statutes 253B.18 subdivision 4c(b) included:
- The patient lacks an appropriate provisional discharge plan.
- A placement that would meet the patient's needs is being developed.
- Funding has not been secured.
Ongoing efforts are being facilitated to enhance discharges for those served at Forensic Services, including:
- Collaboration with county partners to identify those individuals who have reached maximum benefit from treatment.
- Collaboration with county partners to identify community providers and expand community capacity (with specialized providers/utilization of Minnesota State Operated Community Services).
- Utilization of the Forensic Review Panel, an internal administrative group, whose role is to review individuals served for reductions in custody (under MI&D Commitment), and who may be served in a more integrated setting.
- The Forensic Review Panel also serves to offer treatment recommendations that could assist the individual's growth/skill development, when necessary, to aid in preparing for community reintegration. As a result of these efforts, through November 2018, Forensic Services recommended reductions-in-custody to the Special Review Board for 73 individuals, 55 of which were granted, with 11 results pending.
- Collaboration within DHS to expand community capacity and individualized services for a person's transitioning.

Positive Supports Goal Three A, to reduce the number of reports of emergency use of mechanical restraints with approved individuals to ≤ 93 reports and ≤ 7 individuals by December 31, 2019.

Under the requirements of the Positive Supports Rule, in situations where mechanical restraints have been part of an approved Positive Support Transition Plan to protect a person from imminent risk of serious injury due to self-injurious behavior and the use of mechanical restraints has not been successfully phased out within 11 months, a provider must submit a request for the emergency use of these procedures to continue their use. These requests are reviewed by the External Program Review Committee (EPRC) to determine whether or not they meet the stringent criteria for continued use of mechanical restraints. The EPRC consists of members with knowledge and expertise in the use of positive supports strategies. The EPRC sends its recommendations to the DHS Commissioner's delegate for final review and either time-limited approval or rejection of the request. With all approvals by the Commissioner, the EPRC includes a written list of person-specific recommendations to assist the provider to reduce the need for use of mechanical restraints. In situations where the EPRC believes a license holder needs more intensive technical assistance, phone and/or in-person consultation is provided by panel members. Prior to February 2017, the duties of the ERPC were conducted by the Interim Review Panel.

Housing and Services Goal One, to increase the number of people living in the most integrated housing of their choice by 5,547 (or 92%) by June 30, 2019.
- Although the 2018 annual goal was not met, the growth was larger than the previous year. A contributing factor to missing the goal may have been the tight housing market. When there is a tight housing market, access to housing is reduced and landlords may be unwilling to rent to individuals with public assistance, limited rental history, or other similar factors.
Lifelong Learning and Education Goal Two, to increase the number of students with disabilities enrolling in integrated postsecondary education settings by 492 by June 30, 2020.
- While Minnesota saw a decrease in the number of students enrolled in institutions of higher education in fall 2016, students may be choosing to enter into short-term certificate programs, within a technical college for specific skills training. To be considered enrolled in an accredited institution of higher education for the purposes of the Statewide Longitudinal Education Data System (SLEDS) reporting, a student must be on a credit earning track toward a certificate, diploma, two- or four-year degree, or other formal award. In addition, Minnesota continues to have a strong employment outlook and many students with disabilities are choosing to enter the job market in entry-level positions, gaining experience and independence or saving money for college, as higher education expenses continue to be on the rise. SLEDS 2016 data reported that 2,901 (44%) of students with disabilities were employed in competitive integrated employment. Based on a review of disaggregated data, a targeted activity was designed to increase successful postsecondary enrollment results for Black and American Indian students with disabilities. This aligned with MDE's current federal State Systemic Improvement Plan (SSIP). For school year 2017–18, MDE staff collaborated with TRIO Student Support Services currently serving students at institutions of higher education. Using a scale-up approach, for school year 2018–19, MDE will disseminate additional Minnesota Postsecondary Resource Guides at Minneapolis Community and Technical College, Hennepin Technical College, and Fond du Lac Tribal and Community College. In addition, MDE staff will share online training resources that are currently located on Normandale Community College website.
Crisis Services Goal Four A, to increase the percentage of people who are housed five months after discharge from the hospital (due to a crisis) to 84% by June 30, 2018.
- There was an overall increase in the number of individuals receiving services. In June 2017, the number of people receiving services in a treatment facility was nearly double the amount of people receiving treatment in a treatment facility at baseline. This indicates more people were receiving a higher level of care after discharge. This includes Intensive Residential Treatment Services (IRTS) and chemical dependency treatment programs that focus on rehabilitation and the maintenance of skills needed to live in a more independent setting. As noted for Housing and Services Goal One, a contributing factor to missing the goal may have been the tight housing market. When there is a tight housing market, access to housing is reduced and landlords may be unwilling to rent to individuals with limited rental history or other similar factors. DHS is working to sustain and expand the number of grantees utilizing the Housing with Supports for Adults with Serious Mental Illness grants. These grants support people living with a serious mental illness who are residing in a segregated setting, experiencing homelessness, or at risk of homelessness to find and maintain permanent supportive housing. The grants began in June 2016, with a fourth round of grants planned for 2019.

National Core Indicator data from Minnesota from 2016 to 2017 either remained stable or somewhat declined (compared to 2015–2016 data) on most questions about employment, mobility, community engagement, and living opportunities.

December 17, 2018

The Olmstead Subcabinet reviewed and accepted the Quality of Life Survey First Follow-Up Report. This report outlined the results of the Olmstead Quality of Life Survey's first follow-up survey and compared results to baseline survey data collected in 2017. The results of this survey are critically important to understanding how Minnesota is meeting the goals of its Olmstead Plan. The purpose of the Olmstead Quality of Life Survey is to talk directly to Minnesotans with disabilities who receive services in potentially segregated settings to collect individuals' perceptions and opinions about what affects their quality of life. The Olmstead Quality of Life Survey: First Follow-up – 2018 was conducted between June and November 2018. A total of 511 people completed the survey. Key findings included:

There was no significant change from baseline to follow-up in the amount of interaction respondents had with community members during outings.
There was no significant change from baseline to follow-up in respondents' autonomy in choice-making.
There was no significant change from baseline to follow-up in respondents' perspective in 14 different areas including health, happiness, comfort, and overall quality of life.
Overall, respondents listed fewer close relationships in the follow-up sample compared to the baseline (statistically significant change). The average number of close relationships listed in the follow-up sample was 3.7, compared to 4.1 in the baseline sample. However, since the change was less than one person, it is difficult to determine if this was a meaningful change in practical terms. This difference will need further exploration.
Past studies conducted by the developer of the survey showed that noticeable change can only be expected in the short term (about one year) when a large transition has occurred, such as moving from institution to community. Even in these studies, changes become statistically significant only at approximately two years. Given that a large transition like de-institutionalization did not occur during the period of study and the relatively short amount of time between the baseline and follow-up surveys, it is not unreasonable to expect little to no change in survey scores.

This report was intended as a high-level overview of the first follow-up survey results. A detailed technical report describing the relationships outlined in the regression models and survey results by region, service setting, and other individual characteristics was scheduled to be completed in January 2019. A second random sample of baseline respondents will be selected for a second follow-up survey. To provide enough time to see significant changes in module scores between the baseline survey and the second follow-up survey, the recommendation was to conduct the second follow-up survey starting in summer 2020.

The Subcabinet also reviewed and approved the 2018 Annual Report, including data acquired through October 31, 2018. This report included progress toward goals related to:

Movement of people with disabilities from segregated to integrated settings.
Movement of individuals from waiting lists.
Quality of Life measurement results.
Increasing system capacity and options for integration.

This annual report covered the 47 measurable goals in the Olmstead Plan. Thirty-two of the annual goals were either met, on track to be met, or were in process. Fifteen annual goals were not met. A number of major activities were completed or were in process to make improvements in Olmstead Plan implementation in 2019.

In September 2018, the Olmstead Subcabinet examined a Strategic Review of Plan implementation over the three-year period. This review identified significant accomplishments in measurable goals and strategies and workplans, as well as areas that lacked progress on measurable goals that relate to the improvement in the lives of people with disabilities.
In October 2018, the Olmstead Subcabinet completed the third comprehensive review of the Olmstead Plan workplans. Of the 231 workplan activities reviewed in 2018, only 5 were reported as exceptions.
The Subcabinet initiated the third annual Olmstead Plan amendment process. This review will include multiple opportunities for people with disabilities and the public to review and offer suggestions. The process will be completed in March 2019.
During 2017, the Quality of Life Survey was completed. This survey established a baseline. The Olmstead Plan Quality of Life Survey Baseline Report was accepted by the Olmstead Subcabinet on March 26, 2018. Subsequent surveys will use the baseline to measure progress on the Plan's impact on improving quality of life for people with disabilities. The first follow-up survey was completed in December 2018. The following measurable goals were targeted for improvement. These goals were identified as not meeting projected targets. The agencies, OIO compliance staff, and the Subcabinet will provide increased oversight until projected targets are met.
Transition Services Goal Two, to decrease the percentage of people at AMRTC who no longer meet hospital level of care and are currently awaiting discharge to the most integrated setting.
Transition Services Goal Three, to increase the number of individuals leaving the MSH for a more integrated setting.
Lifelong Learning and Education Goal Two, to increase the number of students with disabilities enrolling in integrated postsecondary education settings.
Positive Supports Goal Three A, to reduce the number of reports of emergency use of mechanical restraints with approved individuals.
Positive Supports Goal Four, to reduce the number of students experiencing emergency use of manual restraints.
Crisis Services Goals One and Two, to increase the percentage of children and adults who remain in the community after a mental health crisis.
Crisis Services Goal Four A, to increase the percentage of people who are housed five months after discharge from the hospital (due to a crisis).

Olmstead Draft Plan Amendments were reviewed and accepted by the Subcabinet, to be posted for public comment. For additional details on the Subcabinet's discussion of the draft amendment, see page 4 of the December 17, 2018 Olmstead Subcabinet meeting minutes.

Finally, the Subcabinet reviewed and approved revised Subcabinet procedures. The revisions were made to bring the procedures in line with the proposed language of the Executive Order. To review the changes made, see page 137 of the December 17, 2019 Olmstead Subcabinet meeting materials.