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Adoption of virtual healthcare, self-sufficient wages and paid neighbors concept will ensure optimal living for vulnerable people and their paid caregivers

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Adoption of virtual healthcare, self-sufficient wages and paid neighbors concept will ensure optimal living for vulnerable people and their paid caregivers

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Content Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept Will Ensure
Optimal Living For Vulnerable People And Their Paid Caregivers
By
Kleckner J. Charles
Master of Public Administration, Long Island University C.W. Post, 2001
Bachelor of Art, Stony Brook University, 1992
Capstone Project Submitted in Partial Fulfillment
of the Requirements for the Degree of
Doctor of Social Work
Suzanne Dworak-Peck School of Social Work
University of Southern California
May 2020

Acknowledgments
I would like to express my gratitude to the entire DSW faculty at the USC Suzanne Dwork-Peck
School of Social Work for the exceptional learning I was exposed to over the past two years. A
special note of gratitude to Professor Dr. Jennifer Lewis for her support and guidance leads to
completing this capstone and related requirements.

Table of Contents

Executive Summary .........................................................................................................................
Conceptual Framework .................................................................................................................1
Problems of Practice and Solution(s)/Innovation .......................................................................2
Project Structure, Methodology, and Action Components ......................................................15
Conclusions, Actions, and Implications .....................................................................................31
References .....................................................................................................................................31
Appendix A: Transition Plan For 210 Individuals From ICF to Their Home ...................... A1
Appendix B: MIT ’s Self-Sufficient Wage Scale ....................................................................... B3
Appendix C: Process or Outline For The Paid Neighbors ’ Support...................................... C5
Appendix D: Medical Outcome Survey (Rand Corporation) ................................................. D6
Appendix E: Scoring Instrument For Medical Outcome Survey .......................................... E8
Appendix F: Self-Direction Wage Limits For Live-In Staff ...................................................11
Appendix G: Logic Model ...........................................................................................................12
Appendix H: GANNT Chart ................................................................................................... H13
Appendix I: Budget .................................................................................................................... I14
Appendix J: Prototype ...............................................................................................................J15

Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept
Executive Summary
The grand challenge addressed in this capstone is "closing the health gap." (American
Academy of Social Work & Social Welfare 2016). The wicked problem this innovation will
address is: Over the next decade, thousands of individuals with intellectual and developmental
disabilities (I/DD) who are chronically ill will be sent to institutions (nursing homes, hospitals,
large residential facilities) because there will be no staff available and willing to care for them.
People with IDD make up a small percentage of the United States' population, but they
consume a large portion of healthcare resources. A scan of the health care environment finds
large hospital systems championing virtual health as a means to increase access. On the long-
term care side, BrightSpring Health Services has a proprietary virtual care platform called "Rest
Assured Telecare." This system uses cameras and a staffed 24-hour remote care monitoring
system to provide needed support to the elderly and others with various disabilities. Other
successful virtual health entities include StationMD, which utilizes a proprietary virtual health
platform to remotely provide emergency room visit services. This system is very well known in
the IDD environment, and their intervention has reduced emergency room visits by 38% or more
for the facilities which contracted with this service. Another virtual health provider is Triage
Logic, which provides remote Nursing support.
On the residential side, Google has leveraged its financial resources to benefit individuals
with IDD and their families. This was done to finance a new residential development in San
Diego, California, where 25% of the units will be reserved for people with IDD and their
families. One of the main objectives of this project is to provide housing supports in an
integrated environment. Bethesda, a well-known national organization, is constructing a new
housing development in Victoria, Minnesota. This setting will offer a unique integration model
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept

that caters to the needs of individuals with IDD and seniors simultaneously and in an integrated
environment.
Nationally, there is a long waiting list for individuals with IDD to access the supports
they need. This is impacting hundreds of thousands of aging caregivers, many of them
octogenarian. The direct support workforce is in crisis, and it is facing numerous challenges.
More than 95% of families report difficulties accessing qualified direct support staff (DSP) to
care for their loved ones. This situation will worsen over the next decade as the baby boomers
will need increased support, and they will compete for the services of the same direct care
workforce. To ameliorate this situation, a four-part innovative solution will be deployed. This
innovation aims to engender positive outcomes for individuals with IDD and their support staff
while interconnecting their human rights to optimal living. The four solutions will encompass:
Self-sufficiency for direct care staff, virtual healthcare, paid neighbors, and transitioning people
out of Intermediate Care Facilities (ICF) of 16 beds or more.
This innovation will seek to rebalance existing resources while attaining at least a 50%
cost saving for the system of care. Lastly, this innovation is rooted in robust policies and legal
decisions at the Federal and State level, like the Americans with Disabilities Act (ADA) and
related Olmstead enforcement actions by the United States Justice Department. More
importantly, it will re-affirm the inalienable rights of individuals living in institutions to
transition into integrated settings in the community. This innovation will be implemented
through the prism of the change theory and the concept of care theory. The characteristic of this
innovation and its four components can be best described as sustaining as it seeks to improve
existing aspects within the system of care of individuals with IDD to help close the health gap
while bringing about economic justice for their paid caregivers.
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 1
Conceptual Framework
Statement of the problem
The wicked problem the proposed innovation will address is: Over the next decade,
thousands of individuals with intellectual and developmental disabilities (I/DD), who are
chronically ill, will be sent to institutions (nursing homes, hospitals, large residential facilities)
because there will be no staff available and willing to care for them. In many instances,
individuals with IDD are outliving their parents. In others, their primary caregivers or parents
are too old and not physically capable of caring for them. If these problems were to persists,
they will lead to re-institutionalization and reverse gains made regarding people with IDD over
the past 60 years. During this epoch, thousands of people with IDD transitioned from hospitals,
nursing homes, psychiatric settings, and large residential campuses to small group homes (eight
people or less) in the community.
It is the collective responsibility of society to ensure that the system of care for its most
vulnerable citizens does not revert to the inhumane care paradigm of the past. A few decades
ago, in New York State and other locations throughout the U.S., thousands of individuals with
IDD resided in large institutions and often in decrepit and derelict conditions. There were
hundreds of these institutions around the country; however, the majority of them are shuttered
today. This innovation will focus on the IDD population in New York State. In New York
State, Willowbrook was probably the most infamous of these institutions where the care
provided there was inhumane and abusive. Before the closure of these large institutions
(Willowbrook and others), the New York State agency responsible for the care of individuals
with IDD had operated the most extensive system of institutions since the 19th century (Ericsson
1996).
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 2

Another facet of this problem is that community group homes that have replaced the
long-shuttered institutions are expensive, and they contain some institution-like aspects to them.
Moreover, the Medicaid resources to fund long-term services and support (LTSS) may be
significantly reduced or unavailable in the future. Due to the anticipated increase in demand and
fiscal uncertainty regarding entitlements funding (Medicaid & Medicare). Consequently, the
LTSS for individuals with IDD must evolve and innovate before the end of this decade to avoid
this situation becoming more critical.
This problem was first highlighted nearly ten years ago during an international
symposium in Singapore in a position statement. The authors were members of the Special
Interest Research Group (SIRG) of the International Association for the Scientific of Intellectual
Disabilities CPP SIRG. The consensus was that the community accommodations that have
replaced institutions (group homes, etc.) would need to be reformed themselves as they replicate
many institutional features (Beadle-Brown 2009).
Statement of Relevance of the Problem to one or more of the 12 Grand Challenges
The foundation, anchor, or the raison d'etre for most social innovations are rooted in the
twelve grand challenges of social work. The grand challenge that is the basis of this innovation
is "closing the health gap." The following phrases: Good health outcomes for all and eradicating
health inequalities convey the same concept (American Academy of Social Work & Social
Welfare 2016). The field of social work has evolved over the years to address the complex needs
of society. In the United States, health inequities remain among the more severe and complex
social challenges. All twelve grand challenges are critical to the harmonious and self-fulfilling
existence of the members of society. However, health or closing the health gap remains the most
impactful. The importance of this societal challenge became more cogent during the current
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 3

COVID19 global pandemic that is affecting the world, the United States, New York Metro Area,
and other locations. This epidemic has accentuated health inequities among the vulnerable
people in society, inclusive of individuals with IDD.
Theoretical Perspectives
Two distinct theories undergird this proposed innovation. The first is the change theory,
and the second is the concept of care theory. The change theory is relatively popular in both the
academic and professional realm of social work. However, the concept of care theory is most
frequently applied in healthcare environments, specifically nursing practice. The change theory
involves the listing of long-term goals and aligning them with the general rationale or
assumptions. This theory articulates the steps, milestones, or indicators that will bring about the
outcome related to the long-term goals. Without these milestones, the long-term goal may not be
readily achievable. This dynamic process is called backward mapping (Clarke 2012). This
theory delves into "why" questions concerning the selected steps or procedure to arrive at the
desired outcome. Another aspect involves determining the most strategic interventions to bring
about the desired change (Clarke 2012). The most fundamental element of the change theory
involves a quality review wherein critical indicators correspond with the measurable progress.
Moreover, it involves the following characteristics: Is the theory plausible, feasible, and testable
(Clarke 2012). In terms of this proposed innovation, the logical model, which will be discussed
later, epitomizes components and key characteristics of the change theory and its applicability.
Another school of thought emphasizes listing and prioritizing interventions as a preamble to the
change process (Chalkidou 2019).
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 4

The concept of care theory was inductively derived and validated through research and
investigations in three separate perinatal contexts (Swanson 1991). This theory is very apropos
to this innovation as the healthcare of the individuals with IDD, who will partake in this
innovation, will be overseen by a registered nurse (RN). This theory is termed the middle-range
theory as it is more concrete than the grand theories, and it also has fewer concepts (Cand 2016).
The concept of care theory has five levels. The first level describes that everyone has a capacity
for caring, which is both inherent and influenced by the environment. The second level explains
that beliefs and values underpin caring actions. The third level focuses on conditions and
circumstances that enhance or inhibit caring. The fourth level involves concrete, caring activities
and therapeutic interventions. Lastly, the fifth level postulates that positives and negatives may
result in both intentional and unintentional outcomes for the caregiver and the recipient
(Swanson 2013). The aspect of this theory that is most applicable to this innovation is the role
the environment plays in the caregiving process and how unintentional outcomes can impact
both the caregiver and the recipient.
Research
I/DD Population Classification & Key Supports
People with IDD make up a small percentage of the United States' population, but they
consume a large portion of health care resources. An IDD qualifying diagnosis typically
happens before the age of 22 and through educational testing. The age for the qualifying
diagnosis for IDD does vary from state to state. For instance, in New York, the qualifying
diagnosis must be obtained before the age of 23. Conversely, in California, the qualifying
diagnosis must be received before 18 to be eligible for services.
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 5

Initially, services will be rendered through the Individuals with Disabilities Education
Act (IDEA). The local state education department would pay for most of the support needed,
except for healthcare. The children or young adults with IDD would qualify for this support from
birth through 21 years. If they require support beyond that, it will have to be obtained through
the support system available for adults with at least one qualifying IDD diagnosis.
The current support model for people with I/DD is not sustainable. As of 2016, nine
percent of the 65 million Americans within the age range of 5 to 21 received support through
IDEA (U.S. Department of Education 2018). However, once they have attained the age of 22,
needed supports, such as long-term services and supports (LTSS), will be funded through
existing states' Medicaid waiver programs commonly referred to as the home and community-
based services (HCBS) waiver. The type of Medicaid waiver available depends on the
previously negotiated agreement between the Center For Medicaid/Medicare Standards (CMS)
and the state where the individuals with IDD are domiciled. The two main waiver programs
wherein this negotiation takes place are 1915(c) or 1115. The current transition system that sees
individuals with IDD age out of the educational settings and graduate to the adult system will
continue to place a financial burden on entitlements funding. It is worth noting that this
transition almost always happens with no financial responsibility on the part of their families.
The people who are most at risk in the future are the ones who are characterized as
chronically ill. When there is a shortage of staff, their requirement for complex care will make it
easier for them to be institutionalized (hospital, nursing home, etc.). To accentuate this further,
imagine a 30-year-old individual with the mental age of a five-year-old child (IDD). It is not
unusual for him or her to remain at home with an aging parent, who may be an octogenarian.
However, now imagine the same 30-year-old individual diagnosed with diabetes and insulin-
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 6

dependent. He would be classified as needing chronic care, and this individual has a much
higher chance of being institutionalized (hospitalized, nursing home, etc.).
Most people who receive healthcare services are for episodic health encounters. Meaning
someone who needs knee replacement may end up costing the system about $35k (Weeks 2017).
That individual will not require that same knee to be replaced for at least another 10 to 15 years.
However, for the people with IDD who require chronic care, they will need assistance with the
following: Bathing, Cooking, dressing, taking medications for 50 years or more after they have
entered the adult system of care. As of 2013, LTSS accounted for $347 billion of annual
healthcare costs, and Medicaid paid 51% of the total (Reaves 2015).
Historically, public funding favored costlier institutional care. However, recent
innovative approaches, policies, and legislative changes have been reversing this outdated
pattern (Hickie 2012). The incessant advocacy on the part of the disability rights movement, the
Americans with Disabilities Act (ADA), the Olmstead decision, and subsequent enforcements
have also played a role in reversing this trend. Recent Federal and Supreme court decisions have
all affirmed that unnecessary institutionalization is a form of discrimination. Moreover, the
unjustified isolation of the people with IDD living in these settings is also a form of
discrimination. Advocates and stakeholders affirm that keeping individuals with IDD in these
restrictive settings denies them rights that every citizen enjoys. These include family relations,
social contacts, work options, economic independence, educational advancement, and cultural
enrichment (Dinerstein 2016).
Costly Healthcare System
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The IDD care paradigm must innovate and change before the broader health care system
undergoes significant changes that may have unintended consequences for the people with IDD.
This change is necessary because the United States has, by far, the costliest healthcare system in
the industrialized world. In 2017, the health expenditure per capita in the U.S. was $10,224. This
amount is 28% higher than Switzerland, the next highest per capita spender, and 50% more than
the average spend of the top countries with equal or better overall population health outcomes
than the United States. The total costs for the United States' healthcare system have exceeded
$3.3 trillion, or 17.8% of the gross domestic product (GDP) (KFF 2018).
Several decades ago, the first residential option for people with IDD was in an institution.
Therefore, very few families opted for that support, but now community-based support is the first
option. In 2016, an estimated 1,228,700 individuals with IDD received LTSS in the United
States, and several thousand more remaining on states' waiting lists awaiting. Among those on
the waiting lists are people with IDD who require chronic care.
Nationally, 807,462 people with IDD were on the HCBS waiver, and the total cost for the
ones on the waiver was $35.5 billion or $43,928 per person. $10.8 billion are expended every
year to provide services to individuals with IDD who reside in Intermediate Care Facilities
(ICF). A small total of 74,614 individuals reside in these settings at an average annual cost of
$140,831 per person (Larson 2018). These resources can be better spent to support at least half
of these people in more innovative and integrated settings for substantially less.
Workforce In Crisis
The entire direct care workforce is in crisis due to higher demand related to people
getting older and people with disabilities and chronic diseases living longer. This innovation
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 8

will focus on a subset of direct care workers called direct support professionals (DSP). They
support individuals with IDD across various settings, including private homes, group homes,
vocational and day training programs, and institutions. Although there is no separate
occupational code for direct support professionals, these workers' on-the-job responsibilities tend
to differ significantly from those of direct care workers. These workers numbered more than 1.3
million nationwide as of 2013, and they routinely perform tasks that require more skills and
training than the typical direct care staff (Scales 2013).
This workforce is in crisis due to poor pay, challenging working conditions, and lack of
training. The national turnover rate of the direct support professional staff (DSP) was 46% in
2018. Over the next decade, the aging baby boomer population will increase the demand for
DSP staff (ANCOR 2019). During that time, all baby boomers will be age 65 or older. This new
phenomenon will mean that one out of every five people in the U.S. population would have
reached retirement age. A mere four years later or by 2034, baby boomers will outnumber
children or people under the age of 18 for the first time in U.S. history. According to
projections, the U.S. will have 77.0 million inhabitants over the age of 65 years (U.S. Census
Bureau 2018).
In recent years, several scholars have highlighted the pending direct care crisis that awaits
as the U.S. demographics change, and they offered suggestions on how to ameliorate this
situation. Some of the ideas included providing higher wages. The belief is that higher wages
would make the Long-Term Care (LTC) workers' jobs more appealing and would attract more
applicants. Another suggestion called for creating career ladders and better training while
shifting recruiting efforts targeting unemployed seniors and low-skilled migrants from
neighboring countries (Columbo 2009).
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 9

More Families Want Group Homes & Long Waiting List
Often when it comes to residential care for individuals with IDD, most families want
their loved ones to reside in a small group home for about four individuals in a beautiful
neighborhood with a two-car garage and a small minivan. This desire regarding residential
support is best termed as the Cadillac option. In reality, most of these people would be able to
live fulfilling lives in other home environments that are less costly, more sustainable (fiscally),
person-centered, and more integrated.
The Americans With Disabilities Act (ADA) and the Olmstead Act enforcement actions
by the US Justice Department have been responsible for the total of isolating state institutions
being decreased from 176 to 140 in recent years. The number of individuals living in these
institutions decreased in half, from 39,000 to 19,000 people over ten years (2005 – 2016). This
has contributed to a long waiting list of individuals with IDD in need of HCBS supports in 35
states, with the total unserved reported at 424,000. However, IDD advocates claimed that this
number is a lot high due to a lack of transparency and uniformity in maintaining these waiting
lists (ANCOR 2019).
Affordable Care Act (ACA) & Subsequent Legislations
Several elements of the ACA's policy aim to improve access, reduce costs, and improve
quality. These have had some impact on the care and support for people with IDD who are
chronically ill. However, these changes were not broad and enduring enough to reverse the
trends associated with the wicked problem identified earlier. Some of those impactful steps
included allowing states to redirect Medicaid funding to improve Long Term Care infrastructures
in the community via the expansion of the HCBS. Other provisions included the Balancing
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 10

Incentive Program (BIP), the Community First Choice state plan option, and Money Follow the
Person (MFP) demonstration projects" (Kaiser Family Foundation 2015). These initiatives
provided the needed resources for thousands of individuals with IDD to transition into the
community at a lower overall net cost to the system. At the same time, the remaining funds were
used to enroll additional individuals into the waiver.
Another essential facet made possible by the ACA was the Delivery System Reform
Incentive Program (DSRIP). Through this program, grant funding was made available to States
for innovative endeavors to reduce unnecessary hospitalizations and value-based payment
(VBP). These initiatives were aimed at increasing population health outcomes for certain
categories of Medicaid recipients. Over the previous four years, New York State has awarded
more than $1 billion to hospitals and community-based providers with the intent of reducing
health care costs by reducing hospital stay and emergency room visits. Concerning this
innovation, several IDD providers could procure virtual health services to do remote triage for
individuals with IDD who reside at hundreds of group homes.
Actual Practice
The actual practice or the existing care paradigm for individuals with IDD reveals a
multitude of approaches. They range from routine care in the community to antiquated
institutional care, which still exists in many states. The majority of adults with IDD reside at
home with their families, and they do not receive any type of support outside of routine
healthcare. These individuals continue to live healthy and productive lives as members of their
community. Others who require support tend to receive it through the HCBS waiver. The
primary form of care provided centers around assistance and training with activities of daily
living (ADL). These activities include feeding, bathing, dressing, toileting, transferring,
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 11

continence, and feeding (Katz 1963). Instrumental activities of daily living (IADL) are those
activities that allow an individual to live more independently in the community. Although not
necessary for functional living, the ability to perform IADLs can significantly improve the
quality of life for people with IDD and afford them greater independence. The major domains of
IADLs include Cooking, cleaning, transportation, laundry, and managing finances (Lawton
1969). The supports and training provided to individuals with IDD are aimed at improving their
ADL and IADL skills. They are termed habilitation training or habilitation services.
Day Program / Vocational Program / Day Training
When individuals with IDD transitioned from the institutions into the community several
decades ago, there were subsequent mandates regarding their need to engage in meaningful
activities during the day. Before these individuals attain the age of 22 and graduate from high
school, they are supposed to go through at least three years of vocational assessments. The
reason for this is to help determine the most suitable vocational or day habilitation program,
post-graduation. The assigned programs usually vary according to the individual's level of
functioning (cognitive and physical) and the availability of these programs.
Residential (Home)
For this aspect, it is worth expanding the scope internationally and in the seniors' care
paradigm. From an international perspective, it is probably no surprise to the reader that the
Scandinavian and select Western European countries are more advanced or more attuned to the
human rights of individuals with IDD than the United States as a whole. Several states in the
Union have been very progressive in their approaches for the past several decades. However,
many are regressive and continue to rely heavily on institutional care for people with IDD.
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During the 1990s, the second generation of group homes was developed in the Nordic countries.
These new residential settings were more individualized and afforded individuals with IDD
greater privacy and security. These homes were all situated in residential streets and clustered in
no more than three to five apartments (Tøssebro 2012).
In England, a study revealed that merely moving the individuals with IDD from a large
institution into a small group home on a beautiful residential street does not guarantee true
integration and community connections. Expected contact among neighbors, which usually
involves simple acknowledgment using a greeting nod or wave, was mostly absent between the
individuals with IDD and their neighbors. The study noted that there was always a feeling of
mutual awkwardness. Under normal circumstances, neighbors would see each other as potential
sources of support they could rely on in times of need. However, this reciprocal relationship did
not exist with someone with IDD residing in these group homes (Mansell 1996).
Villages For Individuals With IDD
Several self-contained villages are inhabited by adults with disabilities and their support
staff. Among them are The Village of Merici, Inc. in Indiana, Pathfinder village in New York,
The Village Learning Center in Texas, Annandale Village in Georgia, and a few more scattered
throughout the United States. These villages are appealing to families, as they consist of self-
contained and gated campus environments that keep their loved ones safe. Most of these villages
offer some of the best amenities, but they deprive their residents of true community integration
and connection. These self-contained communities are exclusively for individuals with IDD, and
they are devoid of physical integration. Actual presence in the community is the preamble to
true social integration. This form of immersion occurs when people with and without intellectual
disabilities live in the same neighborhood or community. Whereby they can see, hear, and
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 13

interact with each other. When people with and without intellectual disabilities meet frequently,
they become more familiar with one another (Dinerstein 2016).
Village Support Model For The Elderly
This system of support was studied as part of this innovation since people with IDD are
aging, along with the baby boomer population. They are living longer, and they will require
supports and services that account for their advanced age. This first iteration of a very
innovative residential support model for the elderly population originated with the Beacon Hill
Community in Boston, and it was launched in 1991. In this village, community and social
supports were rallied to help seniors age in place and remain in their homes as long as possible.
This ensured that they did not have to move into nursing homes where they would experience
social isolation. Loneliness is pervasive and inherent in institutions such as nursing homes. This
begets social isolation, both perceived and actual, and increases the risk of poorer health and
mortality. The primary aim of the village programs is to maintain these seniors in the
community where they have long-established social connections (Holt-Lunstad 2015).
Participation in these villages is based on dues, and the types of supports they provide vary
widely. Village members tend to be healthy, but research on several of these villages has found
some challenges related to health outcomes. Nonetheless, these villages have improved quality
of life, sustained social engagement, assisted individuals with daily living needs, and provided
their members with transportation (Graham 2014).
Policies Implementation & Impact on Current Practice
Money Follows the Person (MFP) has been a very impactful policy in the IDD landscape
with regards to transitioning individuals from institutions into the community. This program was
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first authorized under the Deficit Reduction Act of 2005. With the Affordable Care Act (ACA)
passage, which was later amended and re-authorized in 2019 and 2020. Due to grassroots efforts
on the part of advocates and individuals of all abilities, this act was re-authorized (Larson 2018).
MFP provides states with the financial resources and legal flexibility under the Medicaid HCBS
waiver. These resources were used to re-engineer LTSS in many states and ensure that
individuals of all varying abilities (disabilities) have a choice of where they live and receive
services.
Thanks to MFP, more than 75,151 people with chronic conditions and disabilities
transitioned from institutions into the community as of December 2016. During the two
subsequent years (2017 & 2018), an additional 18,640 individuals for a total of 93,791 have left
institutions to reside in integrated communities (Larson 2018). Another impactful policy was the
Community First Choice Option and the No Wrong Door Initiative. These two policies have
made it more accessible for individuals with IDD to remain in the community. In New York
State, these initiatives led to the creation of a uniform and centralized intake process termed the
"front door." It also led to the creation of IDD-centric Health Homes that are regionally based.
Presently, these health homes coordinate the care of more than 140,000 individuals with IDD.
Workforce
In New York State, the gradual adoption of the $15.00 minimum wage and additional
salary enhancements for DSP staff will see their wages rise gradually to nearly $17 per hour in
the downstate region of the state (more prosperous region). However, a recent analysis
sponsored by a stakeholder group found that these salary increases result in a decrease in benefits
in some cases. They may create a net reduction in overall income or render the salary increase
less insignificant as a result of a reduction in public assistance benefits such as housing subsidies
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or food stamps (Cook 2017). In terms of current practice, a very innovative not-for-profit
organization in New Mexico called Encuentro had taken the initiative to create a new home
health aide training for Latino immigrants, which is thought entirely in Spanish. In addition,
they provide financial assistance during this training to cover the costs of tuition and childcare.
Encuentro also launched a matching service registry, called EnCasa Care Connections, which
facilitates consumers and workers to find each other (Scale 2020).
Existing Innovation & Alternative Approaches
The field of IDD does not exist in a vacuum as it is interdependent on the healthcare
system, transportation system, and social networks. Various innovations and their applicability
to the target population will be discussed in the next few pages. These include innovations in
hospitals and long-term care settings.
Google Funded Residential Development (Individuals with & without IDD)
Google has invested more than $5 million in The Kelsey Ayer Station, a residential
development under construction in San Jose, Calif. When completed, this setting will offer units
for rent to people of varying income levels. The hallmark of this project is that it will integrate
individuals with IDD into this community. This will be accomplished by having 25% of the
units reserved for individuals with IDD and their families, and the remaining 75% will be going
to regular renters (Non-IDD). According to executives from Google, this funding is coming
from a $250 million fund set aside to support the construction of more than 5000 new housing
units in the San Francisco area. This residential development applies to this innovation as it will
integrate individuals with IDD into the community. It will also make it easier for them to
establish social connections. One of the drawbacks of this innovation is that it does not account
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for the habilitation support the individuals with IDD will need, nor does it map out a uniform
approach to start integrating them into this community from day one.
Cornerstone Village
This is a new housing development developed in Victoria, Minnesota, by Bethesda, a
well-known national provider in the IDD landscape. This organization is taking a different
approach to integration as it will pair individuals with IDD with seniors to achieve community
integration. According to Bethesda, this residential development will provide individuals with
IDD ample and sustained opportunities to mingle and connect with others or individuals without
IDD outside their families and staff. This complex will consist of 52 units of apartments and
townhouses. The residents of the complex will live independently in their apartments, but they
will have the opportunity to take classes such as exercise and yoga (Read 2019). This program
does move the needle in terms of integration. Still, it does not include a plan to facilitate the
integration of individuals with IDD into this new senior community from day one.
Existing Virtual Health Approaches
A scan of the healthcare environment finds large hospital systems championing virtual
healthcare to increase access. Northwell Health, a multi-billion-dollar health system in the New
York Metro Area, has an E-ICU unit where all physician care is provided remotely. Challenges
remain with Medicaid and Medicare reimbursements for care delivered using virtual health.
Although new allowances have been made in the past couple of months as authorized by the
1135 waiver and The Federal Emergency Declaration (CMS 2020). This was done in response
to the COVID-19 pandemic. The recent allowances under virtual health (telehealth)
reimbursements will expire as soon as the emergency declaration expires. Large hospital
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 17

systems and private insurers have historically negotiated their own reimbursement rules for care
provided using telehealth (virtual health). New virtual healthcare technologies are not typically
available to agencies supporting individuals with I/DD. Historically, this population is the last
group to benefit from these initiatives, which is presently the case.
A multibillion-dollar and publicly traded business entity called BrightSpring Health
Services has a proprietary virtual care platform called "Rest Assured Telecare." This is a virtual
support system that involves cameras and a 24-hour staffed remote care monitoring system.
Remote care staff from a centralized location provide oversight and immediate assistance to the
elderly individual or person with IDD being monitored. This system depends on another
responsible primary caregiver, such as a group home staff or a family member. To date, this
system is used primarily with the elderly population. However, it does hold some promise and
may end up being utilized more frequently in the future to help support individuals with IDD in
LTSS settings or their homes. More recently, BrightSpring has been marketing this system to
organizations that operate group homes for individuals with IDD. This is to enhance the existing
staff supervision at the group homes. Despite the promises, this system will not yield the
substantial cost savings that will be necessary to disrupt the current group home residential
support system (Rest Assured 2019).
Two other virtual health systems currently utilized in the IDD field are StationMD, which
provides virtual emergency room visits to provider organizations, and Triage Logic offers
telenursing triage to group home providers. Both organizations have provided support to IDD
providers in New York State using healthcare innovation grant funding. These two systems are
helpful but limited in their scope. They fail to address the challenges related to the costs
associated with delivering LTSS to individuals with IDD who require chronic care. Of all of the
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 18

virtual healthcare systems mentioned herein, StationMD has the best system for this innovation.
They will be the provider of choice for the virtual healthcare aspects of this innovation.
Problems of Practice & Solutions Innovation
Before delving into the proposed innovation, the target population should be discussed.
This writer hopes that the reader is not under the impression that the forthcoming innovation
would encompass all individuals with IDD in New York State. Such a population would be too
broad and would necessitate a different conceptual framework. The total population of
individuals with IDD in New York State is more than 140,000, and they are overly complicated
(Goldberg 2016). Circa early 2018, this writer recalled listening to a podcast on NPR. On that
day, a seasoned social activist was interviewed regarding the critical changes that lay ahead.
While the interviewee emphasized doom and gloom throughout, she ended by saying the
following: "We will innovate the hell out of whatever situation we are confronted with during the
Trump administration. We are social workers, and we are innovators (Unknown NPR 2017)."
This was said in anticipation of the drastic cuts Trump was supposed to have initiated during his
administration. These reductions have not occurred to date. Medicaid block grants, an increase
in the minimum retirement age, and other entitlements cut may occur eventually. Whether they
happen under the Trump administration or some other administration will be foretold by time.
The Trump tax cuts, the projected COVID19 spending of nearly $7 trillion, and the additional
spending shortfall that preceded it, will need to be paid eventually.
The target population for this proposed innovation consists of people with IDD who are
classified as requiring chronic care. The term chronic condition refers to a physical or mental
health condition that lasts more than one year and affects the individual's overall functioning or
requires regular treatment. Some examples of these conditions include diabetes, hypertension,
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 19

mood disorders, etc. (Buttorff 2017). Initially, this innovation will target 1372 individuals in
New York State who reside in ICF with 16 residents or more. The average annual cost for each
ICF resident in New York State is $213,468. The total yearly expenditure for 1372 individuals is
at least $292,878,096. The share for the New York State taxpayers is $146,439,048, given the
50% Federal Medicaid Assistance Percentages (FMAP) (Larson 2018).
The Concept of Care Theory affirms that the environment in a 16+ bed ICF is not
conducive to proper care. Moreover, these settings influence the staff's perception of the people
with IDD and vice versa. Lastly, it will frequently lead to positives and negatives that may result
in both intentional and unintentional outcomes for the caregiver and recipient (Swanson 2013).
Given the most conservative figures regarding staff turnover in a given year, a resident from a
given 16 bed ICF may have as many as 60 different DSP staff assist him or her with feeding,
bathing, etc.
The ICF setting does not always result in isolation, but it makes it particularly
challenging to build meaningful and reciprocal community relations. Ten states, including the
District of Columbia, have no ICF of 16 beds or more. They are Alaska, Georgia, Michigan,
Oregon, Alabama, the District of Columbia, Hawaii, New Mexico, Vermont, and West Virginia.
The goal is to have New York become the eleventh state before the end of this decade (Larson
2018).
Innovative Components
This innovation consists of four parts, taken in their singularity; each concept or idea
does not seem that innovative nor moves the needle significantly to close the health gap. Real
and lasting impact will occur through the combining of all four subparts. The most central
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 20

people in this innovation are the individuals with IDD, as, without them, none of this would be
possible. The first part of the innovation calls for 210 of the 1372 ICF residents to transition
from their current ICF placement to their own home in the community where they will live with
a DSP staff and possibly the family of the DSP staff. This innovation will happen while
attaining a 50% cost savings over the current ICF care model.
Seven New York State Department of Health regions have been identified. Each region
will have an allotment of 30 individuals, and there will be one agency selected per region using
the state's traditional request for program (RFP) process. Following the selection of the seven
agencies, they will approach the care managers for the health homes to identify and select the
210 individuals who are most suitable for this innovation. This transition and initial adjustment
will happen according to the steps outlined in the attached document (refer to Appendix A).
The second component of the innovation consists of paying a self-sustaining wage to the
cohabitating DSP. Self-sustaining wage entails how much income is needed for a family of a
particular composition in a given locality to meet their basic needs without public or private
assistance. This scale is calculated using MIT's self-sufficient wage multiplied by eight hours
per day X seven days X 52 weeks ($17.99 X 7X 52) = $52,386.88 (refer to appendix B). This
wage is exempt from Federal income tax withholding. However, New York State taxes,
Medicare, and Social Security taxes are not exempted. This was clarified in formal
correspondence from the IRS denoting the following: An eligible individual receiving care in
the individual care provider's home under a Medicaid waiver program is a "qualified foster
individual." To ensure the tax-exempt status, the cohabitating DSP should not support more than
five individuals with IDD at the same time (Driscoll 2014). One of the intended outcomes is to
provide stability to the DSP workforce and reverse the high turnover rate. With this innovation,
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 21

it is anticipated that the DSP staff's longevity will be ten years or more, and they will have better
job satisfaction. The factors that will impact this are not having to commute to work, higher
income, and not having to worry about housing.
The third component of this innovation involves the utilization of virtual healthcare. The
virtual health provider that will be utilized is StationMD. The reason for the selection is this
business entity's extensive experience within the IDD and LTSS landscape in New York State
and around the nation. Moreover, during prior correspondence and interactions with key
personnel at StationMD. They were amenable to letting the staff from the provider organizations
share the same hardware and possibly software to communicate with and monitor the individuals
with IDD and their caregiving staff (cohabitating DSP). Lastly, StationMD offers monitoring
plans that could be used per diem or for a pre-negotiated monthly fee. Before the individuals
move into their new home, the virtual healthcare equipment will be secured by the Care
Manager, and they will be funded by the Managed Care Organization (MCO). Presently, this
virtual health system is used solely to avert emergency room visits. However, this innovation
calls for the entire treatment team to use this system to provide wraparound or whole-person
support to the 210 individuals who will transition out of the ICF.
The last component of this innovation is the paid neighbor concept. This is used on a
limited basis for a few individuals with IDD who have elected to self-direct their services and
with the help of a support broker. The paid neighbor support is usually limited to emergency or
standby support. However, in this innovation, the neighbors will be used as the primary conduit
to further the integration process for the individual with IDD. They will also serve as secondary
support for the cohabitating DSP. The attached chart depicts all of the expectations related to the
paid neighbor concept (refer to Appendix C).
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 22

The positive outcomes that will be derived from this aspect of the innovation are: Stable
social connections for the individual with IDD, the affirming of secondary support for the
cohabitating DSP staff, and the ability to leverage the two paid neighbors for the additional
unpaid community supports or volunteers for the individual with IDD. In keeping with the
tenets of the change theory, periodic reviews will be done to ascertain that progress is made
toward achieving the outcomes related to paid neighbors. For the Concept of Care Theory, the
environment largely determines the type of care that is provided. It is envisioned that the use of
the paid neighbors' concept will engender a friendlier, more welcoming, and most integrated
community for the individual with IDD.
Explanation of Selected Solution (Impetus)
This writer's first professional job following graduation from college was as a DSP. To
that end, this innovation was conceptualized with the lenses of inherent reverence for individuals
with all forms of disabilities and the people who care for them (both paid and unpaid).
Moreover, this innovation is an ideal opportunity to interconnect the closing of the health gap for
individuals with IDD with economic justice (self-sufficient wage) for their paid caregivers
(DSP). The paid neighbors' concept emanates from social norms such as "it takes a village" and
"communities take care of their own." This approach has been remarkably successful in helping
seniors age in their home (in place) in the previously described "village model of care."
Stakeholders' Perspectives & Likelihood of Success
Unquestionably, the most important people in this innovation are the individuals with
IDD. This is their lives, their choice, and they have an alienable right to self-determination and
to live an optimal life. However, they will rely on both natural supports (parents, siblings,
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 23

friends, relatives, etc.) and paid supports to decide whether transitioning into a new home would
be in their best interest. The New York State Medicaid Director, the New York State Division of
Budget (DOB), who are charged with balancing increased demand for services while trying to
close a $2.5 billion Medicaid spending gap for fiscal year (F.Y.) 2021 (McKinley 2020), would
view this innovation very favorably. Self-advocates and their lobbying organization, Self-
Advocacy Association of New York State (SANYS), would think positively of this innovation as
it provides people with disabilities with the opportunity to live independently. Progressive
organizations may view this innovation as a great way to diversify the array of services they
provide to individuals with IDD. Other organizations, such as those currently operating the large
ICFs, may view this innovation unfavorably as it will disrupt their status quo and lead to lower
revenue. The MCO and the State's Planning Council would favorably view this innovation as it
will seek to provide better health outcomes while achieving a 50% cost reduction. Lastly,
Families and individuals with IDD may be apprehensive initially as they may have some
concerns regarding privacy related to the use of the virtual healthcare aspect of this innovation.
However, following their education about the entire process and affirming that the locus of
control will always remain with the individual being supported in the new home.
Purely from a fiscal perspective, this innovation will be successful as it will seek to
rebalance existing resources while achieving a high return on investment (ROI). The two
dilemmas that may impede success are: The self-sufficient wage for the DSP staff and privacy
concerns associated with cameras, etc. (virtual healthcare). Both issues are extraordinarily
complex, and they will have to be managed effectively to ensure long-term success. More
specific details will be shared in the ethical concerns sections and prototype sections. Besides,
the success of this innovation will be supported by various existing state and federal policies and
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 24

practices. It will rebalance healthcare resources, which is one of the pillars of the ACA. It is also
aligned with MFP practice, which CMS has been supporting for almost a decade through various
grants. Lastly, it is backed by the ADA and Olmstead, which sanction the individual with IDD's
right to self-determination.
Implementation Framework
The implementation framework for this innovation is best aligned with EPIS, which
includes the following phases: Exploration, Preparation, Implementation, & Sustainment (EPIS).
According to EPIS, the exploration phase for this innovation began when this writer approached
key stakeholders and industry experts several months ago and agreed on the principle that the
field of IDD must innovate. This process will continue through the communication phase and
the lobbying, outreach, and advocacy work that will be done through the 501 (C) 4 organization
(Coalition For Optimal Living). This phase calls for potential barriers and facilitators of
implementation to be identified. Furthermore, for the necessary adaptation to be made to the
implementation plan while addressing potential barriers (Moullin 2019).
The implementation phase, which the preparation phase will precede, consists of ongoing
monitoring of the implementation process while adjusting as needed. This will be achieved by
the following: The transparent data dashboard reporting on Key Performance Indicators (KPI)
and the annual and semiannual learning collaborative meetings the please refer to Gantt Chart
(appendix F). In this phase, particular attention will be paid to this innovation's inner and outer
context, and adjustments will occur accordingly. The self-reporting of data outcome regarding
customer satisfaction and the health outcome surveys will inform the needed changes for both
inner and outer (Moullin 2019).
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 25

Measuring Success & Program Evaluation
The proposed innovation described above consists of four subsets: transitioning 210 ICF
residents to their new home in the community, paying a self-sustaining wage to the DSP staff
who will live with these 210 residents, utilization of virtual healthcare, and paid neighbors
concept. While the logic model denotes several outcomes (refer to appendix G), but for program
evaluation purposes, the questions below will be incorporated into the measurement process.
Are the 210 individuals who left the ICF to move into their new home healthier than their peers
in the group home? Is the retention of direct support staff (clinical and non-clinical) above 90%,
or is the staff turnover rate less than10%? In terms of the social determinants of health, do the
210 individuals have at least twice as many social connections as comparable peers who reside in
group home settings?
A similar grouping of individuals will be used for this evaluation. Measurements will
contrast by age, gender, acuity level, etc. During the fourth year of this innovation, a thorough
analysis of the ROI will be done using the Scan Foundation's ROI Calculator Tool. This is an
industry-accepted tool that will be used to capture and quantify all cost savings. These system-
wide cost reductions may include measurement of associated savings related to the lower staff
turnover rate, decreased E.R. visits, and lower overall utilization of healthcare. Other
quantifiable data are related to the quality of life and new social connections related to the social
determinant of health. It is well known and accepted today that variables associated with the
social determinants of health affect overall health, wellbeing, and mortality (Tabbush 2016).
Better Health Outcome Evaluation
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 26

The Rand Corporation 36-item health survey (SF-36) (Appendix D) (Rand 1992) and its
accompanying measuring instruments will be used to measure health outcomes (Appendix E).
This survey will be done at six-month intervals and 30 to 60 days before the 210 individuals
transition out of the ICF. Once completed, survey data will be contrasted for 36 months to
validate the prediction that these individuals became healthier by moving into their new home
where they have established better social connections.
Ethical Considerations
Concerning the data collection process, most individuals will not be able to consent to
participate in any of the surveys. To that end, the necessary consent will be sought from their
advocates or parents. Informed consent will also be obtained for the use of the virtual healthcare
system on an annual basis. To ensure greater stability in the lives of individuals with IDD and
their cohabitating DSP, the primary lessor or owner of the dwelling will be the individual with
IDD who resides there. He or she will, in turn, sublease a portion of the apartment to the DSP
staff. An Ombudsperson will be appointed for individuals who do not have active families and
friends advocating on their behalf. Each person who will transition out of the ICF will be
involved in selecting all of the staff who will be supporting him or her. The selection of the
home, which must be situated in an integrated setting, will be made using a person-centered
planning process where interests, likes, and dislikes will be considered. All of the residents will
be provided with due process and assistance from the State's Mental Hygiene Legal Services
(MHLS) throughout the admission process.
Prototype & Communication Plan
The accompanying prototype focuses on advocating for one thing principally. It is the
self-sustaining wages for the direct care staff. Without this aspect, a stable workforce cannot be
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 27

assured. Moreover, many of the staff will continue to need to receive public assistance. If it
were not for the poverty wages provided under the current "live-in" or "shared-living" format,
this innovation would be operationalized in the next few months using existing self-directed
services as a framework. Under the existing self-direction, shared living, family-care, or live-in
staff, the compensation for the cohabitating DSP would be capped. In addition, the
predetermined amount represents less than half of the total salary or the self-sufficient wage this
innovation calls for. Please refer to Appendix F, which represents the guidance provided by the
state agency Office For People With Developmental Disabilities (OPWDD) regarding self-
direction.
Concerning the communication plan, three key organizations have been identified as
potential partners to aid in this process. The first organization is Partners Health Plan (PHP)
www.phpcares.org, which is New York State's first managed care plan exclusively dedicated to
people with intellectual and other developmental disabilities. The second organization is the
Developmental Disabilities Planning Council (DDPC). The federal Developmental Disabilities
Act of 2000 requires that each of the 56 U.S. States and Territories identify Developmental
Disabilities (D.D.) Council to empower individuals with developmental disabilities and their
families to help shape policies that impact them (106th Congress 2000). The third organization
is the Self Advocacy Association of New York State (SANYS) www.sanys.org. This is an
organization founded by and led by people with developmental disabilities for people with
developmental disabilities.
Many great ideas have ended up not succeeding because they did not have the right
messaging or dissemination plan. For instance, the "Say no to drugs" campaign of the 1980s was
cited as a spectacular failure. This writer risked this innovation and associated ideas never
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 28

coming to fruition without the right dissemination plan. Consequently, this innovation will
incorporate a new 501 (c) 4 not-for-profit advocacy organization to house and promote the
various components of this innovation. This organization has a fully functional website, and
topic-related messaging will involve social media and short-form videos. Individuals with IDD
and their families will be included in the majority of the messaging. The newly created 501 (c) 4
organization is called the Coalition For Optimal Living www.coalitionforoptimalliving.org. A
501 (c) 4 not-for-profit designation was selected in lieu of a traditional 501 (c) 3, not for profit,
because the (c) 4 designation will enable the organization to engage in political lobbying. These
advocacy activities will occur both at the State and Federal level to further its stated mission.
Moreover, the formation of this organization will make it easier to attract financial contributions.
Logic Model / Criteria for Success
This is a pictorial representation of the various pathways, as described under the Change
Theory. It identifies the overarching goals of this innovation to close the health gap and attain
better health outcomes for individuals with IDD. The other sections include input in terms of the
resources used to achieve the outcome or overall impact (refer to appendix G). In addition to the
key outcomes listed in the logical model, the true hallmark for success will be to "close the
health gap" by having the individuals with IDD become healthier. Another essential variable
involves not having their caregiver or cohabiting DSP rely on public assistance while working
full time. Success will be monitored in a very transparent manner. A dashboard will capture and
analyze the health data obtained through the Rand Corporation healthcare survey. Identifying
information about the individuals will be kept confidential. However, key indicators such as staff
turnover rate, satisfaction survey, health survey, adherence to budget allocation will be compiled
per agency and system-wide. All of the data milestones will be shared via this data dashboard
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 29

and in a transparent manner. During the semiannual and annual learning collaborative meeting,
various issue-specific committees will be formed to analyze selected data sets and recommend
changes to key pathways. This is in keeping with the tenets of the change theory.
Budget & Affordability
This innovation involves the re-distribution of resources as it will seek to support the 210
individuals with IDD at cost savings of at least 50% or below the current average ICF cost for
New York State. The average annual cost for an individual with IDD in an ICF was reported at
$213,468 (Larson 2018). Half of this amount would be $106,734. The total revenue amount is
derived by taking $106,734 multiply it by 30 (individuals) while adding the housing subsidy.
Please refer to Appendix I for the detailed budget for this innovation. The number of service
units per individual will be 12, and billing will be done monthly. The total number of units per
agency will be 30 per month or 360 units per annum. The projected annual saving to the system
will be $22,414,140. This was calculated by taking the 50% cost saving of $106,734 per
individual and multiplying it by 210 or the total number of individuals.
Summary
Vulnerable people in society, such as the individuals will IDD, are at risk of being re-
institutionalized. The group that is most at risk are people who require chronic care. A small
group of individuals who reside in large ICF use a disproportionate amount of LTSS resources.
Many of these individuals may be able to live in their own homes in the community at 50%
percent of the current cost or less. The current DSP workforce is in crisis, and this crisis will
worsen if the inadequate compensation they receive remains at the current level and the turnover
rate remains at 46%.
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 30

Moreover, as the number of people over the age of 65 increases, there will be a higher
demand for direct care staff, and this will have an adverse effect on a DSP workforce that is
already at risk. There is a long waiting list for LTSS services in the U.S., and this need is
expected to increase. In a not too distant future, many parents who have to keep their adult son
or daughter with IDD at home will become too old and too frail to care for them.
A four-part innovation is recommended for transitioning vulnerable people from high-
cost settings to lower-cost settings. This plan also calls for self-sufficient wages, paid and
unpaid community support (neighbors), and virtual healthcare. Coalition For Optimal Living, a
501 (c) 4, not for profit entity, has been created to pave the way for this innovation. This entity
will engage in lobbying for the policy changes necessary to realize all four components of the
proposed innovation. Closing the health gap for individuals with IDD may be an insurmountable
challenge if it fails to incorporate the "economic gap" for the DSP staff or their paid caregivers.
It was mentioned earlier that the most important people in this innovation are the individuals
with IDD. Still, the second most important people are the DSP staff who care for them every day.

Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 31

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Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 1
Appendix A
Transition Plan For 210 Individuals From The ICF To Their Home
Activities Rationale Responsible Personnel
Complete necessary assessments and
ensure that they are current (CAS & I
AM)
Coordinated Assessment Scale (CAS) is
an acuity scale to determine the level of
support that will be required
Care Manager
CAS Assessor
Complete the budget for each
individual and send it to MCO for
approval. Limited to 50% of current
ICF costs
This is necessary to ensure proper
planning; resource allocation and
ascertain that an outcome indicator of
50% cost saving is being achieved.
Community Support Manager & Health
Home Care Manager
Hire and select new live-in staff with
the individual's participation with IDD
and his or her family. In the event of
no parental involvement, an advocate
will be assigned
This should happen no later than 30
days before the transition into the new
home
Community Support Manager
Complete health satisfaction survey 30
– 60 days before transitioning out of the
ICF
This will ensure the proper monitoring
outcome related to better health.
Community Support Manager
Procure StationMD virtual Hardware to
be made at new home and schedule in-
service training sessions for all
involved (Individual with IDD,
cohabitating DSP staff, R.N., and
Behavior support staff
This is to ensure the seamless operation
of the system from day one. More
importantly, to ensure that remoted
support from the entire support team is
readily available with the first hour of
transitioning into the new home.
Community Support Manager & Health
Home Care Manager
Registered Nurse (RN) will check in
using virtual health once a week and
examine the individual with IDD in
person once per quarter.
This ensures adequate nursing oversight
for the individual with IDD, who is
transitioning from a setting where in-
person nursing support was readily
available.
Assigned R.N. from new agency
Recruit and hire paid neighbors with the
assistance of the individual with IDD,
his or her cohabitating staff, and
advocate. The paid neighbor must be
within a 10-minute radius from the
house—the closer the proximity, the
better. Hire will only take place
following the state's mandated criminal
and child abuse background checks.
This will aid with the integration
process whereby this individual is
viewed as a respected member of his
community.
Community Support Manager
Complete satisfaction surveys every
three months during the first year and
annually thereafter.
This is in keeping with the tenet of
Swanson's Concept of Care Theory.
Moreover, to monitor outcomes related
to satisfaction.
Agency Quality Assurance staff
Disenroll or gradually reduce the
individual with IDD from any day
program and work with the DSP staff to
replace these with activities that are
available in the community such as
swimming, dance and yoga lessons, etc.
and volunteering to help the less
fortunate in his immediate community
such as helping out the elderly
individuals.
This is to replace the old and costly
system of care that involved a day
program at the cost of $25,000 to
$40,000 per year. Some of these
resources can be used to secure more
person-centered and more integrated
services.
Community Support Manager
Work on securing other non-paid
neighbors as volunteers
To expand his social connections within
his new neighborhood or community.
Cohabitating DSP & Community
Support Manager
Obtain signed consent for the use of the
StationMD virtual hardware
This is to ensure the resident's right to
privacy is being observed.
Community Support Manager
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 2

Furnish the individual's apartment and
get subleasing agreement signed by the
DSP staff confirming that she is renting
her portion of the housing from the
individual. She is authorizing that the
rent gets deducted from her bi-monthly
stipend (as per the agency payroll
schedule).
This is to ensure that the placement of
the individual is never in jeopardy and
overall stability in the event the DSP
staff decides to leave the position.
Community Support Manager
The community support manager will
compile individual and aggregate data
and be prepared to discuss them during
the semiannual learning collaborative.
Expected data points will include:
Resource budget adherence; the number
of incidents as defined by OPWDD;
health outcome survey, and customer
satisfaction survey.
This information will be crucial in
terms of adhering to the tenets of the
change theory. All of the information
from the 210 individuals transitioned
will be used to inform the change
theory term as the pathways leading
backward from the outcome.
Community Support Managers from all
participating agencies

Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 3

Appendix B
MIT's Self-Sufficient Wage Scale
Living Wage Calculation for New York County, New York
The living wage shown is the hourly rate that an individual in a household must earn to support his or herself and their family. The assumption is
the sole provider is working full-time (2080 hours per year). The tool provides information for individuals, and households with one or two
working adults and zero to three children. In the case of households with two working adults, all values are per working adult, single or in a
family unless otherwise noted.
The state minimum wage is the same for all individuals, regardless of how many dependents they may have. Data are updated annually, in the
first quarter of the new year. State minimum wages are determined based on the posted value of the minimum wage as of January one of the
coming year (National Conference of State Legislatures, 2019). The poverty rate reflects a person's gross annual income. We have converted it to
an hourly wage for the sake of comparison. For further detail, please reference the technical documentation here.

1 ADULT
2 ADULTS
(1 WORKING)
2 ADULTS
(BOTH WORKING)

0 Child
ren
1 Ch
ild
2 Child
ren
3 Child
ren
0 Child
ren
1 Ch
ild
2 Child
ren
3 Child
ren
0 Child
ren
1 Ch
ild
2 Child
ren
3 Child
ren
Living
Wage
$17.99
$32.
91
$42.95 $56.57 $24.95
$29.
43
$32.08 $37.02 $12.47
$17.
83
$22.87 $29.06
Povert
y Wage
$6.00
$8.1
3
$10.25 $12.38 $8.13
$10.
25
$12.38 $14.50 $4.06
$5.1
3
$6.19 $7.25
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 4

1 ADULT
2 ADULTS
(1 WORKING)
2 ADULTS
(BOTH WORKING)

0 Child
ren
1 Ch
ild
2 Child
ren
3 Child
ren
0 Child
ren
1 Ch
ild
2 Child
ren
3 Child
ren
0 Child
ren
1 Ch
ild
2 Child
ren
3 Child
ren
Minim
um
Wage
$11.10
$11.
10
$11.10 $11.10 $11.10
$11.
10
$11.10 $11.10 $11.10
$11.
10
$11.10 $11.10

Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 5

Appendix C
Process or Outline For The Paid Neighbors' Support
Person With IDD Who Transitioned From
Group Home
Paid Neighbors (minimum of two)
Selects paid neighbors $200 will be deposited into a health resource
account by the fifth day of each month by the
provider agency.
May terminate the relationship with a paid
neighbor at anytime
$2400 annually, which can only be spent on
health expenditures (food and housing).
Matching is based upon common interests
(i.e., both love the N.Y. Yankees or both
love fishing)
Must reside in the immediate community and
must be willing to commit to at least one year.
Responsible for paying the total costs of
$4800 from the annual resource account
($2400 per paid neighbor).
Must be at least 16 years old, and two paid
neighbors can come from the same household
(a couple).
Will have at least four meaningful
interactions with each neighbor per month
Can earn social credits for going above beyond
the mandated four meaningful interactions per
month (awards and recognition).
Care Manager will attest to the frequency of
these meaningful of these interactions every
quarter.
The Health resource account ($2400 per
annum) is taxable and transferable.
Must not reject the majority of the
meaningful interactions initiated by the paid
neighbors.
Must pass New York State's mandated
criminal and child abuse background checks.

Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 6

Appendix D
Rand Medical Outcomes Survey
Item Short Form Survey Instrument (SF-36) RAND 36-Item Health Survey 1.0 Questionnaire Items
Choose one option for each questionnaire item. 1. In general, would you say your health is:
1 - Excellent 2 - Very good 3 - Good 4 - Fair 5 - Poor
2. Compared to one year ago, how would you rate your health in general now? 1 - Much better now than one year a
go 2 - Somewhat better now than one year ago 3 - About the same 4 - Somewhat worse now than one year ago 5 -
Much worse now than one year ago HEALTH
The following items are about activities you might do during a typical day. Does your
health now limit you in these activities? If so, how much? Yes, limited a lot Yes, limited a little No, not limited at all
3. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports 1 2 3
4. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf 1 2 3
5. Lifting or carrying groceries 1 2 3 6. Climbing several flights of stairs 1 2 3
7. Climbing one flight of stairs 1 2 3 8. Bending, kneeling, or stooping 1 2 3 9. Walking more than a mile 1 2 3
10. Walking several blocks 1 2 3 11. Walking one block 1 2 3 12. Bathing or dressing yourself 1 2 3
During the past 4 weeks, have you had any of the following problems with your work or
other regular daily activities as a result of your physical health? Yes No
13. Cut down the amount of time you spent on work or other activities 1 2
14. Accomplished less than you would like 1 2 15. Were limited in the kind of work or other activities 1 2
16. Had difficulty performing the work or other activities (for example, it took extra effort) 1 2
During the past 4 weeks, have you had any of the following problems with your work or
other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? Yes No
17. Cut down the amount of time you spent on work or other activities 1 2
18. Accomplished less than you would like 1 2 19. Didn't do work or other activities as carefully as usual 1 2
20. During the past 4 weeks, to what extent has your physical health or emotional
problems interfered with your normal social activities with family, friends, neighbors, or
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 7

groups? 1 - Not at all 2 - Slightly 3 - Moderately 4 - Quite a bit 5 - Extremely
21. How much bodily pain have you had during the past 4 weeks? 1 - None 2 - Very mild 3 - Mild 4 - Moderate 5
- Severe 6 - Very severe 22. During the past 4 weeks, how much did pain interfere with your normal work
(including both work outside the home and housework)? 1 - Not at all 2 - A little bit 3 - Moderately 4 - Quite a bit
5 - Extremely These questions are about how you feel and how things have been with you during the
past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.
How much of the time during the past 4 weeks... All of the time Most of the time A good bit of the time Some of the
time A little of the time None of the time 23. Did you feel full of pep? 1 2 3 4 5 6
24. Have you been a very nervous person? 1 2 3 4 5 6 25. Have you felt so down in the
dumps that nothing could cheer you up? 1 2 3 4 5 6 26. Have you felt calm and peaceful? 1 2 3 4 5 6
27. Did you have a lot of energy? 1 2 3 4 5 6 28. Have you felt downhearted and blue? 1 2 3 4 5 6
29. Did you feel worn out? 1 2 3 4 5 6 30. Have you been a happy person? 1 2 3 4 5 6
31. Did you feel tired? 1 2 3 4 5 6
32. During the past 4 weeks, how much of the time has your physical health or emotional
problems interfered with your social activities (like visiting with friends, relatives, etc.)? 1 - All of the time 2 - Mos
t of the time 3 - Some of the time 4 - A little of the time 5 - None of the time
How TRUE or FALSE is each of the following statements for you. Definitely true Mostly true Don't know Mostly
false Definitely false 33. I seem to get sick a little easier than other people 1 2 3 4 5
34. I am as healthy as anybody I know 1 2 3 4 5 35. I expect my health to get worse 1 2 3 4 5
36. My health is excellent 1 2 3 4 5 ABOUT
The RAND Corporation is a research organization that develops solutions to public policy challenges to help make
communities throughout the world safer and more secure, healthier and more prosperous. RAND is nonprofit, nonpa
rtisan, and committed to the public interest. 1776 Main Street Santa Monica, California 90401-3208
RAND® is a registered trademark. Copyright © 1994-2016 RAND Corporation

Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 8

Appendix E
Scoring Instrument Medical Outcome Survey
The RAND 36-Item Health Survey (Version 1.0) taps eight health concepts: physical
functioning, bodily pain, role limitations due to physical health problems, role limitations due to
personal or emotional problems, emotional wellbeing, social functioning, energy/fatigue, and
general health perceptions. It also includes a single item that provides an indication of perceived
change in health. These 36 items, presented here, are identical to the MOS SF-36 described in
Ware and Sherbourne (1992). They were adapted from longer instruments completed by patients
participating in the Medical Outcomes Study (MOS), an observational study of variations in
physician practice styles and patient outcomes in different systems of health care delivery (Hays
& Shapiro, 1992; Stewart, Sherbourne, Hays, et al., 1992).
Scoring Rules for the RAND 36-Item Health Survey (Version 1.0)
We recommend that responses be scored as described below. A somewhat different scoring
procedure for the MOS SF-36 has been distributed by the International Resource Center for
Health Care Assessment (located in Boston, MA). Because the scoring method described here (a
simpler and more straightforward procedure) differs from that of the MOS SF-36, persons using
this scoring method should refer to the instrument as RAND 36-Item Health Survey 1.0.
Scoring the RAND 36-Item Health Survey is a two-step process. First, precoded numeric values
are recoded per the scoring key given in Table 1. Note that all items are scored so that a high
score defines a more favorable health state. In addition, each item is scored on a 0 to 100 range
so that the lowest and highest possible scores are 0 and 100, respectively. Scores represent the
percentage of total possible score achieved. In step 2, items in the same scale are averaged
together to create the 8 scale scores. Table 2 lists the items averaged together to create each
scale. Items that are left blank (missing data) are not taken into account when calculating the
scale scores. Hence, scale scores represent the average for all items in the scale that the
respondent answered.
Example: Items 20 and 32 are used to score the measure of social functioning. Each of the two
items has 5 response choices. However, a high score (response choice 5) on item 20 indicates the
presence of limitations in social functioning, while a high score (response choice 5) on item 32
indicates the absence of limitations in social functioning. To score both items in the same
direction, Table 1 shows that responses 1 through 5 for item 20 should be recoded to values of
100, 75, 50, 25, and 0, respectively. Responses 1 through 5 for item 32 should be recoded to
values of 0, 25, 50, 75, and 100, respectively. Table 2 shows that these two recoded items should
be averaged together to form the social functioning scale. If the respondent is missing one of the
two items, the person's score will be equal to that of the non-missing item.
Table 3 presents information on the reliability, central tendency, and variability of the scales
scored using this method.
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 9

Table 1
Step 1: Recoding Items
Item numbers Change original
response category *
To recoded
value of:
1, 2, 20, 22, 34, 36 1 → 100

2 → 75

3 → 50

4 → 25

5 → 0
3, 4, 5, 6, 7, 8, 9, 10, 11, 12 1 → 0

2 → 50

3 → 100
13, 14, 15, 16, 17, 18, 19 1 → 0

2 → 100
21, 23, 26, 27, 30 1 → 100

2 → 80

3 → 60

4 → 40

5 → 20

6 → 0
24, 25, 28, 29, 31 1 → 0

2 → 20

3 → 40

4 → 60

5 → 80

6 → 100
32, 33, 35 1 → 0

2 → 25

3 → 50

4 → 75

5 → 100
* Precoded response choices as printed in the questionnaire.
Table 2
Step 2: Averaging Items to Form Scales
Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 10

Scale Number of items After recoding per Table 1,
average the following items
Physical functioning 10 3 4 5 6 7 8 9 10 11 12
Role limitations due to physical health 4 13 14 15 16
Role limitations due to emotional problems 3 17 18 19
Energy/fatigue 4 23 27 29 31
Emotional well-being 5 24 25 26 28 30
Social functioning 2 20 32
Pain 2 21 22
General health 5 1 33 34 35 36
Table 3
Reliability, Central Tendency, and Variability of Scales in the Medical Outcomes
Study
Scale Items Alpha Mean SD
Physical functioning 10 0.93 70.61 27.42
Role functioning/physical 4 0.84 52.97 40.78
Role functioning/emotional 3 0.83 65.78 40.71
Energy/fatigue 4 0.86 52.15 22.39
Emotional well-being 5 0.90 70.38 21.97
Social functioning 2 0.85 78.77 25.43
Pain 2 0.78 70.77 25.46
General health 5 0.78 56.99 21.11
Health change 1 — 59.14 23.12
Note: Data is from baseline of the Medical Outcomes Study (N=2471), except for "Health
change," which was obtained one year later.

Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 11

Appendix F
Live-In Caregiver Maximum Reimbursement Levels
As of 10/01/2014, the maximum Live-in Caregiver reimbursement levels* are as follows:
Rate Setting Region 1 – New York City
Rate Setting Region 2 – Putnam, Rockland, Westchester, Suffolk and Nassau Counties
Rate Setting Region 3 - Rest of State
Rent - $17,676 annually Food - $5,000 annually Utilities - $ 3,500 annually Annual Total -
$26,176 Monthly Max - $2,181
Rent - $19,200 annually Food - $5,000 annually Utilities - $ 3,500 annually Annual Total -
$27,700 Monthly Max - $2,308
Rent - $13,872 annually Food - $5,000 annually Utilities - $ 3,000 annually Annual Total -
$21,872 Monthly Max - $1,823
*These are the maximum amounts by Region. Actual amount allowed in a person’s budget will
be limited by certain factors including county of residence, number of bedrooms and calculations
determined by the ISS formula and the Self-Direction Budget (excepted from the Self-Direction
Guidance to Providers 2015).

Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 12

Appendix G

Disruptive LTSS Care Model For I/DD

Overarching Goals:

Full Community Inclusion
& acceptance

Self-Sustaining wage for
new co-habitating DSP

Paid and unpaid
neighborly supports

Better health outcome

Achieve cost savings of at
least 50% over the ICF
rates
INPUTS

OUTPUTS
Participants - Activities - Direct Products
Identify
cohorts of
individuals
with I/DD

Identify or
create a village
or supportive
community

Determine
available
resources

Identify and
interview care
giving DSP

Procure virtual
health
equipment
from
StationMD

Identify jobs
and activities

Select paid
neighboards

Care Manager

Community
support
manager

Technology
vendor
(StationMD)

MCO
personnel

Local
Medicaid or
state
representative

DDPC
Personnel

Members of
the NYS self-
advocacy
group

Review list of
individuals

Meet with
local real
estate agent
and/or
developer

Ensure CAS
and IAM
assessments
are completed

Prepare
Lifeplan & set
up regular
team meetings

Provide
needed virtual
equipment
training

Undergo
background
checks for
perspective
staff

30 individuals
with I/DD in
20 to 30
different
settings

Finding
property and
secures
funding

Determines
the level of
supports

Everyone is
trained

OUTCOMES - IMPACT
Short term - Intermediate - Long-Term

Individuals
with I/DD
are safe and
living in
their new
home

Individuals
with I/DD
are
receiving the
same level of
healthcare
in the group
home using
virtual
technologies

The
neighbors
know the
individuals
with I/DD
by name

Individuals
with I/DD are
healthier now
that they have
a permanent
home and a
family (social
determinant
of health)

Hold
successful
learning
collaborative
meetings
semiannually

Other levels of
staff (RN, psy)
are using the
virtual health
hardware to
support the
individuals

Hastened the
closure or
reduction of all
ICF that are 16
beds or lager

This innovation
is starting to be
utilized for all
individuals with
IDD who seek
greater
independence

Hire individuals
with IDD who
benefited from
this innovation
as a
spokesperson
for this
innovation

Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 13

Appendix H
Gantt Chart

Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 14

Appendix I

Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 15

Appendix J Prototype: Advocacy Brief

Adoption of Virtual Healthcare, Self-Sufficient Wages and Paid Neighbors Concept 16

Abstract (if available)

Abstract The grand challenge addressed in this capstone is ""closing the health gap."" (American Academy of Social Work & Social Welfare 2016). The wicked problem this innovation will address is: Over the next decade, thousands of individuals with intellectual and developmental disabilities (I/DD) who are chronically ill will be sent to institutions (nursing homes, hospitals, large residential facilities) because there will be no staff available and willing to care for them. ❧ People with IDD make up a small percentage of the United States' population, but they consume a large portion of healthcare resources. A scan of the health care environment finds large hospital systems championing virtual health as a means to increase access. On the long-term care side, BrightSpring Health Services has a proprietary virtual care platform called ""Rest Assured Telecare."" This system uses cameras and a staffed 24-hour remote care monitoring system to provide needed support to the elderly and others with various disabilities. Other successful virtual health entities include StationMD, which utilizes a proprietary virtual health platform to remotely provide emergency room visit services. This system is very well known in the IDD environment, and their intervention has reduced emergency room visits by 38% or more for the facilities which contracted with this service. Another virtual health provider is Triage Logic, which provides remote Nursing support. ❧ On the residential side, Google has leveraged its financial resources to benefit individuals with IDD and their families. This was done to finance a new residential development in San Diego, California, where 25% of the units will be reserved for people with IDD and their families. One of the main objectives of this project is to provide housing supports in an integrated environment. Bethesda, a well-known national organization, is constructing a new housing development in Victoria, Minnesota. This setting will offer a unique integration model that caters to the needs of individuals with IDD and seniors simultaneously and in an integrated environment. ❧ Nationally, there is a long waiting list for individuals with IDD to access the supports they need. This is impacting hundreds of thousands of aging caregivers, many of them octogenarian. The direct support workforce is in crisis, and it is facing numerous challenges. More than 95% of families report difficulties accessing qualified direct support staff (DSP) to care for their loved ones. This situation will worsen over the next decade as the baby boomers will need increased support, and they will compete for the services of the same direct care workforce. To ameliorate this situation, a four-part innovative solution will be deployed. This innovation aims to engender positive outcomes for individuals with IDD and their support staff while interconnecting their human rights to optimal living. The four solutions will encompass: Self-sufficiency for direct care staff, virtual healthcare, paid neighbors, and transitioning people out of Intermediate Care Facilities (ICF) of 16 beds or more. ❧ This innovation will seek to rebalance existing resources while attaining at least a 50% cost saving for the system of care. Lastly, this innovation is rooted in robust policies and legal decisions at the Federal and State level, like the Americans with Disabilities Act (ADA) and related Olmstead enforcement actions by the United States Justice Department. More importantly, it will re-affirm the inalienable rights of individuals living in institutions to transition into integrated settings in the community. This innovation will be implemented through the prism of the change theory and the concept of care theory. The characteristic of this innovation and its four components can be best described as sustaining as it seeks to improve existing aspects within the system of care of individuals with IDD to help close the health gap while bringing about economic justice for their paid caregivers.

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Asset Metadata

Creator Charles, Kleckner J. (author)

Core Title Adoption of virtual healthcare, self-sufficient wages and paid neighbors concept will ensure optimal living for vulnerable people and their paid caregivers

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Publication Date 04/23/2021

Defense Date 05/27/2020

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Ada,caregivers,closing the health gap,CMS,Crisis,direct care staff,group home,health care costs,ICF,intellectual disabilities,New York State,OAI-PMH Harvest,Olmstead Act,paid neighbors concept,remote monitoring,unpaid caregivers,virtual healthcare,waiting lists,workforce

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Lewis, Jennifer (committee chair)

Creator Email drkleckjcharles@gmail.com,kjcharle@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-453102

Unique identifier UC11668434

Identifier etd-CharlesKle-9514.pdf (filename),usctheses-c89-453102 (legacy record id)

Legacy Identifier etd-CharlesKle-9514.pdf

Dmrecord 453102

Document Type Capstone project

Rights Charles, Kleckner J.

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA