13:00:09  ROSA PLASENCIA:

13:00:12  Welcome, all.

13:00:15  I am happy to welcome you to our webinar

13:00:18  titled

13:00:19  'Empowering Choice - Exploring 
Self-Direction Experiences Among National 
13:00:22 Core Indicators Respondents"'.

13:00:23  This is a joint effort of several speakers

13:00:27  and associations. 
My name is Rosa Plasencia
13:00:30 .

13:00:31  This webinar was spearheaded by HSRI

13:00:34  (indiscernible)

13:00:35  in memory of our colleague Sarah Taub

13:00:38 .

13:00:41  We have an incredible group of speakers and 
I will ask them to introduce themselves.
13:00:48  VALERIE BRADLEY:

13:00:50  Hi, I am Val Bradley. 
The president
13:00:52  of

13:00:53  the Human Services Research Institute

13:00:55 .

13:01:04  My (indiscernible) goes back to the 1990s 
when we worked on the (unknown name) 
13:01:09 demonstration and it has been a passion of 
mine ever since, so, welcome.
13:01:14  LINDSAY DUBOIS: Hello, my name is Lindsay 
DuBois.
13:01:18  My pronouns are she, her. 
I am a middle-aged white woman in my office 
13:01:23 and behind me are pictures my children have 
drawn.
13:01:27  I am wearing a white shirt and have blonde 
hair and glasses. Thank you for joining us.
13:01:34  MOLLY MORRIS: Hello, I am Molly Morris, the 
vice presidentst
13:01:40  at Applied Self-Direction. 
I use she, her pronouns. I am a middle-aged 
13:01:44 woman with white, blonde hair

13:01:46 .

13:01:51  I have a black turtleneck on with a floral 
background. Looking for to talking with 
13:01:56 everyone today. 
ALICIA BOEHME:
13:01:57  Hi, I am Alicia Boehme

13:01:59 .

13:02:06  I am a white woman with brown hair and 
brown eyes and I'm sitting in my living room 
13:02:13 with a couch and art and piano in the 
background. Good to see everyone.
13:02:18  CHRISTIAN MORAN:

13:02:28  Good afternoon. 
My name is Christian Moran, I am also from 
13:02:32 the Wisconsin Department of Health Services 
I am a white, middle-aged man with a shaved 
13:02:37 head and a beard. 
I am wearing a blue sport coat and a white 
13:02:42 shirt. 
I am in my small, home office. Happy to be 
13:02:46 here. 
ROSA PLASENCIA: Thank you so much, everyone. 
13:02:49 I apologize, I missed my visual description. 
I am a middle-aged woman with light, 
13:02:54 although skin, wavy hair and a blue 
turtleneck. I have a cold today so I am 
13:02:59 sorry about that. 
Participants will be muted during this 
13:03:03 webinar. 
Please use the q and a feature in the chat.
13:03:07  Toward the end of the webinar panelists 
will be
13:03:10  participants will be able to

13:03:15  ask and have their questions answered.

13:03:17  ,

13:03:17  ..

13:03:18 .

13:03:25  Live Spanish interpretation can be accessed 
by clicking the interpretation button at the 
13:03:30 bottom of your zoom screen which is the 
world icon. (indiscernible) silenced the 
13:03:35 original audience (audio issues)

13:03:37  audio.

13:03:38  (Speaks Spanish)

13:03:39 .

13:03:48  Due to a recent Zoom

13:03:50  update,

13:03:53  full accessibility may not work if you are 
joining with a mobile devices and slides
13:03:59  can no longer be viewed

13:04:03  simultaneously via tablet or phone. 
Please swipe to find the ASL Interpreter on 
13:04:07 your mobile device. 
This webinar includes polls's
13:04:10  and we appreciate your interaction 
throughout
13:04:12 .

13:04:19  Slides will be available on our website at 
a later date. Val, I will turn it over to 
13:04:26 you. 
Thank you. VAL BRADLEY: Hi, this is Val 
13:04:29 again. 
I neglected to say I am a middle aged woman,
13:04:33  well, no, that is not true (Laughs) I am a 
much older woman with red hair, wearing a 
13:04:39 black sweater with white stripes. 
I am sitting in my somewhat cluttered office 
13:04:44 with plants and bookcases behind me. 
I use she, her pronouns.
13:04:51  This webinar is named after a colleague of 
ours, a dear colleague of ours named Sarah 
13:04:56 Taub. 
Before she passed away, Sarah was the
13:04:59  National Core Indicators Director

13:05:01  until 2013

13:05:03  when a very aggressive cancer took her life

13:05:06 , much to all of our sorrow.

13:05:09  Her mission and purpose was really

13:05:11  the central part

13:05:16  of the growth of NCI and has made it what 
is today
13:05:20 . 
She was a very fierce advocate for people 
13:05:24 with disabilities and advocated for the 
representation at all levels
13:05:27  of the work that we do.

13:05:30  She never really that as forget who

13:05:32  were the people behind the numbers.

13:05:36  That is why we have called these webinars 
he Sarah Taub
13:05:40  Webinars.

13:05:41  This is what we call

13:05:47  hope you will get out of this webinar 
today. First, to increase your knowledge in 
13:05:53 general about self-direction and people's 
experiences with self-direction.
13:05:57  We want to share some best practices, some 
exemplary practices
13:06:00  that will hopefully

13:06:03  give you some ideas about how to expand the 
opportunity for self-direction
13:06:08  in your states. 
We want to show how NCI data
13:06:11  highlight the characteristics and outcomes

13:06:13  of people who are using self-direction.

13:06:16  And then we want to speculate on some of 
the additional areas
13:06:21  that we really should be exploring in the 
future.
13:06:29  So, now we want to take a minute just to 
find out who is in our audience
13:06:38  and for you to give us a bit of a 
self-assessment about how familiar you are 
13:06:44 with self-direction. 
We are going to Luntz launch a poll.
13:06:52  Can you describe yourselves?

13:06:57  Just check

13:06:59  whichever best characterizes you

13:07:03 .

13:07:12  OK, now we need to go to the next poll, is 
that right, Laura?
13:07:27  So, please rate your knowledge of 
self-direction supports.
13:07:30  Zero

13:07:32  being next to nothing. 
Five
13:07:34  being a lot

13:07:35 .

13:07:49  Great, and Laura,

13:07:51  are we ready to see the results?

13:07:59  OK, in terms of knowledge,

13:08:01  some people with a lot of knowledge

13:08:04 ,

13:08:05  and a bit of knowledge

13:08:07 .

13:08:08  It looks like a fairly knowledgeable group

13:08:13  with some people still here to learn more. 
That is great, thank you
13:08:18 . 
And have about who is here, Laura?
13:08:27  We have a few people with lived experience.

13:08:30  A few more family members and advocates

13:08:32 .

13:08:34  We've got some public managers working at 
the state level
13:08:38 ,

13:08:38  case managers who are absolutely crucial to 
this whole process
13:08:42 ,

13:08:43  some policymakers, service providers and 
some researchers
13:08:45 .

13:08:47  A real, interesting, diverse group. 
Thank you so much
13:08:50 .

13:08:54  Let us do a brief overview of the history 
of self-direction
13:08:58 .

13:08:59  In the traditional model,

13:09:02  which I assume you are all pretty familiar 
with,
13:09:05  the public money goes directly to the 
provider.
13:09:09  And the services are basically driven by 
the case manager
13:09:12  and the service provider.

13:09:14  We call that sort of a wholesale model

13:09:17 .

13:09:17  The self-direction model is really more of a

13:09:20  (indiscernible).

13:09:23  The public funds go to an individual's 
support budget
13:09:26  and it is up to the individual

13:09:28  to determine which services

13:09:30  they want to purchase

13:09:32 ,

13:09:34  which goods and services they want to take 
advantage of
13:09:38 .

13:09:38  The responsibility of forming the service 
packages on the individual
13:09:42 .

13:09:51  In my judgment self-direction is part of a 
larger human right that we all have to 
13:09:57 self-direction. 
Which asserts that we all should have agency 
13:10:01 in our lives and that we have control over 
the decisions that really determine the 
13:10:06 course of our lowers lives.

13:10:08  Self-direction really reflects the promise 
of self-direction
13:10:10  by putting power in the hands of people

13:10:13  who need supports

13:10:21  (audio issues)

13:10:22 .

13:10:23  Here is a brief timeline

13:10:25 .

13:10:26  These are sort of some of the major 
milestones
13:10:30  over time.

13:10:33  Important to know that self-direction goes 
back even to 1953 in California
13:10:37 , where people who were covering

13:10:41  recovering from polio were given the 
ability to purchase their own
13:10:45  personal care attendants. 
That program is now part
13:10:48  of a huge service provided in California.

13:10:56  In the 1980s, Massachusetts and a few other 
states had pressure from the independent 
13:11:01 living movement gave people with physical 
disabilities the ability to purchase their 
13:11:05 own personal care attendants.

13:11:06  1995 Cash and Counseling came along which 
made it possible to cash out certain public 
13:11:12 benefits, for older adults, people with 
physical
13:11:15  disabilities, to use the money to use as 
they wish for the services they needed
13:11:21 .

13:11:21  The amount of institutionalization among 
the group went down as a consequence
13:11:26 . 
In 1997, the (unknown name)
13:11:28  funded (indiscernible)

13:11:29 .

13:11:30 ..

13:11:31  2003

13:11:36  self-direction became a service option for 
multiple groups
13:11:39  through the use of HCBS waivers.

13:11:42  And in 2023,

13:11:46  a year before last, there were 260 
self-direction programs
13:11:50  throughout the country

13:11:53  serving a total of 1,520,267 individuals

13:11:55 .

13:11:56  How do we know that? 
Because of our friends
13:11:59  at Applied Self-Direction,

13:12:01  who you will hear from next. 
Molly?
13:12:07  MOLLY MORRIS:

13:12:12  Val, I think you have one more slide to 
cover. You want me to jump in? VAL BRADLEY:
13:12:22  Very quickly. 
Sorry. Because self-direction is not a 
13:12:25 national program with national standards and 
expectations, states vary significantly and 
13:12:29 how to implement self-direction. 
Some states
13:12:31  use their own state case managers to be 
support
13:12:35  (indiscernible), other states contract, 
some states allow people to have their own
13:12:40  personal facilitator or personal agent

13:12:41  as part of their budget.

13:12:44  The supports that people are likely to 
purchase
13:12:47  very widely from state

13:12:49  to state,

13:12:50  including staffing and goods and services

13:12:53 .

13:12:56  Populations in each state may vary the 
magnitude of those populations
13:13:00 .

13:13:00  And finally, there are a multitude of 
funding authorities
13:13:04  that states

13:13:05  (indiscernible)

13:13:07  support self-direction

13:13:09  including (unknown name)

13:13:15  Older Americans Act, state general fund and 
even a veterans administration
13:13:19  program for self-directed Veteran Directed 
Care. Now I will posit
13:13:23  pass it on to our good friend, Molly.

13:13:26  MOLLY MORRIS:

13:13:28  Thanks so much, Val, happy to be here. 
I am with
13:13:32  an organization called Applied 
Self-Direction.
13:13:34  Some background about us

13:13:40  is that we are a mission driven 
organization and our focus is on advancing 
13:13:45 some direction, understanding all things 
self direction. We try to serve as a 
13:13:50 national hub that really provides technical 
assistance, training, community, building to 
13:13:54 be that resource around this model. 
We serve many different stakeholders
13:13:58  from state agencies

13:14:00  to financial management services, service 
providers, managed care organizations to 
13:14:04 participants advocacy groups, support 
brokers.
13:14:07  Basically all of you and the different 
categories you indicated on the
13:14:12  survey, we are here to be a resource.

13:14:15  I am going to be

13:14:20  giving some background and context that I 
think is going to be giving you
13:14:25  a bit of the lay of the land

13:14:29  when we get more into what Lindsay is going 
to talk about with the findings on 
13:14:35 self-direction from the National Core 
Indicators study. I will give you a sense of 
13:14:40 the broad landscape nationally of the growth 
of self-direction, pulling from our recent, 
13:14:44 Self-Direction National Inventory from 2023. 
The project was really all about measuring
13:14:49  the breadth and scope of self-direction 
offerings across the country.
13:14:53  This is a study we have conducted every 
three years since 2011.
13:14:57  We have that historical data that continues 
to give us a better picture of trends
13:15:02  year-over-year.

13:15:03  The data that we collected in 2023 is 
notable for a couple of reasons
13:15:08 . 
One,
13:15:09  it was the first time we did an inventory 
post pandemic
13:15:17  and so, we wanted to know what was the 
impact of the pandemic specifically on 
13:15:23 self-direction? 
I will talk about that in a bit. We 
13:15:26 coincided with a huge wave of new interest 
in self-direction, both at the participant 
13:15:31 and program level. 
And while we have seen consistent, steady 
13:15:35 growth every three years that we have 
measured, we sought a sharper rate of 
13:15:40 enrollment in 2023. 
More states implementing new programs and 
13:15:43 program expansions that at any point in the 
previous decade.
13:15:50  It's exciting and I will talk more about 
that in a moment.
13:15:57  A bit more context about our methods. 
Sorry, it looks like the text is a bit small 
13:16:03 on the slide. 
I do not know how that happened but the 
13:16:07 program data I will refer to today was 
collected from October I do not know how 
13:16:13 that happened but the program data I will 
refer to today was collected from October 
13:16:17 2022 through February 2023 so I generally 
refer to it as 2023 data. We collected the 
13:16:22 data through initially very in-depth review 
of publicly available documentation about 
13:16:26 publicly funded self-direction programs. 
Then we conducted interviews, we were able 
13:16:29 to have 65 interviews with state staff from 
43 states,
13:16:32  and we did have at least some form of 
correspondence, including email with 
13:16:36 administrators in every state. 
In a few cases, and Roman Tama
13:16:39  -- data is not available for self-direction 
from administrators.
13:16:44  We were able to contact financial services 
providers to provide that data
13:16:47  or we used enrollment estimates that are 
often included
13:16:50  in Medicaid documentation.

13:16:54  Finally, as a quality check, we work with a 
community of
13:16:57  state administrators and financial

13:16:58  management services providers that

13:17:02  applied self-direction, we shared our 
initial data with that group
13:17:08  as a quality check to make sure that the 
numbers we collected kind of looked right to 
13:17:13 people in the industry who no particular 
programs.
13:17:18  I talked about the spike in enrollment

13:17:21 .

13:17:25  From 2019 to 2023, we actually saw 23% 
increase enrollment
13:17:28 . 
By comparison, from
13:17:30  2016 to 2019

13:17:31  it was a 17% increase

13:17:33 .

13:17:34  That is a bigger spike

13:17:35  that we were excited to see

13:17:38 .

13:17:41  As Val mentioned, we had found 1.5 million 
people self directing
13:17:45  nationwide.

13:17:45  For perspective on this, I have a chart

13:17:50  on the slide and you can see that in 2011, 
there was about
13:17:55  700,000

13:17:55 + people self directing.

13:17:57  Year over year 2013 that was

13:18:00  up to 800,000+

13:18:01 .

13:18:06  2019 we got to 1.2 million and then up to 
1.5
13:18:10 .

13:18:10  You can see this is a program that just 
continues to grow
13:18:15 .

13:18:17  Of course

13:18:19 , I was just talking about national numbers

13:18:22 ,

13:18:24  but self-direction enrollment increases do 
vary state to state
13:18:27 .

13:18:30  When we collected this data in 2023, most 
states reported an increase in self-direction
13:18:36  enrollment. 
That was 44 states.
13:18:37  But if you did report a decrease.

13:18:41  As Val mentioned, California was an early 
adopter of self-direction
13:18:45  and it is a large state.

13:18:50  In our national accounting of enrollment, 
it has always tended to be well over 50% of 
13:18:56 people self directing live in California. 
That percentage has continued to decrease.
13:19:04  In 2023, for the first time less than 50% 
of people self directing live in California.
13:19:11  That shows that nationally we are showing 
greater growth but not saying California is 
13:19:16 getting smaller. 
We also had six states that more than 
13:19:20 doubled self enrollment. 
Alabama, Connecticut, DC, Florida, Maryland, 
13:19:23 South Dakota had huge leaps.

13:19:27  I will spend a few minutes talking about 
some major trends that we have seen
13:19:32  from this data and from our interviews with 
states.
13:19:37  One is that there are a variety of 
different funding sources for 
13:19:42 self-direction, publicly available funding 
sources. By far the Medicaid 1915(c)
13:19:47  waiver is the most frequently used source 
but other authority uses are growing.
13:19:51  I will talk about that in a bit.

13:19:56  We talk a lot about Medicaid self-direction 
but the veterans health administration
13:20:00  also has their own

13:20:01  self-direction program called Veteran 
Directed Care.
13:20:05  Really exciting. 
From 2019 to 2023
13:20:07  we saw 157%

13:20:10  increase in enrollment

13:20:11 ,

13:20:14  which is the difference between an average 
of 33 veterans per site
13:20:19  288 veterans per site. 
Huge, huge growth.
13:20:22  On the next slide we will talk briefly 
about why that is
13:20:27 . 
For one, the veterans health administration 
13:20:29 is really committed

13:20:32  to making Veteran Directed Care available 
to every Veterans Affairs Medical Center by 
13:20:37 2026. 
Just this month the Elizabeth Cole HCBS act
13:20:41  was signed into law which also has some 
really ambitious goals for Veteran Directed 
13:20:46 Care. 
Exciting to see that growth.
13:20:50  Availability of self-direction varies by 
population.
13:20:52  Most all states provide at least one

13:20:55  Medicaid funded self-direction offering

13:20:57  for adults over age 65

13:20:58 ,

13:20:59  for adults with physical abilities

13:21:05  disabilities and adults with intellectual 
and develop mental disabilities
13:21:08 .

13:21:13  It is less available as an option for other 
populations, for instance, people with 
13:21:18 serious mental illness, children who are 
medically fragile. It is not like these 
13:21:22 programs are available in every state all of 
the time but we are hearing from states they 
13:21:28 are signaling more interest in expanding 
these options. That is a trend to watch.
13:21:33  As I mentioned, the COVID pandemic really 
did make a significant impact.
13:21:38  People were looking to receive care at home 
and have more control over their care. Also
13:21:45  as I think many of you know, the majority 
of states created temporary emergency 
13:21:50 options via their appendix K allowing for 
legally responsive individuals to provide 
13:21:55 care which is an important feature of 
self-direction.
13:21:58  States also talked about self-direction as 
filling a critical void when a lot of other 
13:22:03 services were shutting down and there was 
significant federal funding during this time 
13:22:08 period that helped galvanize the model.

13:22:10  It is important to note

13:22:12  that in self-direction there is both the 
option
13:22:15  of having employer authority, were you 
choose your own workers
13:22:19 , and, or, budget authority,

13:22:22  where you have decision-making power over 
your budget
13:22:25 , can set the rate of wages for your workers

13:22:29  and can even

13:22:32  in some cases purchase goods and services 
that support your independence
13:22:36 . 
In 2023 we found states that demonstrated 
13:22:39 the most growth in Medicaid funded enrollment

13:22:41  also tended to offer budget authority.

13:22:44  It starts to tell us a story that perhaps 
the more flexibility we give
13:22:49 , the more people are opting into 
self-directed.
13:22:52  More than ever,

13:22:54  we are seeing states have more 
sophisticated funding structures
13:22:57 ,

13:22:58  specifically pairing their 1915 C waivers

13:23:02  with other funding authorities including 
state plans
13:23:04 ,

13:23:05  which in some ways it really signals

13:23:07  embedding self-direction more permanently

13:23:09  in the structure of the state

13:23:11 .

13:23:12  In some cases making it

13:23:14  something that everyone is eligible for

13:23:17  that meets the criteria.

13:23:22  We also looked closely at the workforce

13:23:25 .

13:23:30  Obviously there is a self-direction, and 
overall workforce crisis impacting the home 
13:23:34 and community-based services sector.

13:23:35  Several states reported that self-direction 
mitigated
13:23:42  workforce shortages, particularly being 
able to hire paid family makes a difference 
13:23:46 but at the same time

13:23:49  we also heard from states that 
self-direction is in no way exempt from 
13:23:54 these concerning patterns in the direct care 
workforce crisis. We need to keep an eye on 
13:23:59 this. 
Lots of areas for future workforce to 
13:24:02 understand including what could be the 
positive impact of increased wages and 
13:24:07 benefits? 
What is the impact of paid family caregiving 
13:24:10 unavailability of workforce? 
And what is the impact of budget authority? 
13:24:14 We see that plays an important role as well. 
There is a lot of potential in the future to 
13:24:21 do deeper research, particularly working 
with financial management
13:24:23  service providers, using the data they 
already collect often times through their 
13:24:28 state contracts.

13:24:33  Future research that we are looking towards 
coming out of this most recent inventory as 
13:24:39 we are preparing for the next one is again, 
continuing conversations about workforce. 
13:24:44 How self-direction can scale to support 
historically marginalized and underserved 
13:24:47 communities. 
is going to be really critical. Not everyone 
13:24:50 has equal access to self-direction. 
Understanding the difference in unmet needs
13:24:54  and people who self directing people using 
traditional services.
13:24:58  And also understanding some of those states 
that had a decrease enrollment. What is that 
13:25:03 due to? 
Obligated enrollment processes?
13:25:05  EVV

13:25:07  implementation not going well?

13:25:15  With that said I think it covers trends 
normal pass things over to Lindsay. Thanks, 
13:25:20 everybody for stopping the Mac thanks, Molly.

13:25:31  This slide shows a timeline of the surveys 
that comprise the National Core Indicators 
13:25:36 for NCI. 
NCI tools collect data
13:25:40  on performance and quality of life directly 
from people who use disability and, or aging 
13:25:45 service systems, their families and those 
who deliver services. Since the first NCI 
13:25:50 intellectual and develop mental disability 
survey, or NCI-IDD in 1997,
13:25:53  we have had 48 states participate.

13:25:56  Since launching the NCI aging

13:26:00  (unknown name) or NCI-AD in 2013, we have 
had 26 states participate
13:26:05 . 
We also hear from 30 states...
13:26:09  Five on the NCI state of the workforce

13:26:11 .

13:26:13  On the next slide we have the goals of our 
NCI tools
13:26:17 . 
Really, there are three angles.
13:26:21  To establish a nationally recognized set of 
performance and outcome into quarters
13:26:28  indicators for aging and disability service 
systems.
13:26:34  To use valid and reliable data collection 
methods and statistical techniques to 
13:26:38 capture information directly for people who 
use services. And report those individual 
13:26:43 state results

13:26:44  (audio issues) national benchmarks of the 
surveys
13:26:46 . 
If you have questions you can check out
13:26:50  our website. 
The link should be in the chat
13:26:53 .

13:26:55  I wanted to touch briefly on the overall 
methods for collecting NCI data
13:27:00 . 
States work closely with (unknown name)
13:27:04  to design samples to be representative of 
their surface population
13:27:07 .

13:27:09  On the AD survey, this is anyone who 
receives one active service
13:27:13  at least twice a week from their state

13:27:16  aging and disability service system, that 
is the eligible population
13:27:19 . 
On the idea decide you need to be receiving 
13:27:23 at least one service in addition to case 
management.
13:27:26  All of the surveyors that collect the data

13:27:34 ..

13:27:35 .

13:27:38  Confidentiality is important.

13:27:44  Since COVID many states have offered both 
in person, or remote interviews to complete 
13:27:49 the surveys. 
We have the surveys in multiple languages 
13:27:52 and we allow for these proxies for selected 
questions.
13:27:56  On the next slide we have a map showing the 
18 states who dissipated
13:28:01  in the 2022/2023 NCI AD

13:28:03 .

13:28:06  Altogether we heard from more than 15,000 
individuals of which about one third were 
13:28:11 male, average age was 67.

13:28:14  We see a fairly diverse sample in terms of 
race, ethnicity and diagnosis
13:28:18 .

13:28:20  On the next slide we have a map showing the 
33 states that participated in the 2022
13:28:27 - 2023 NCI- IDD.

13:28:37  Altogether we heard from more than 25,000 
individuals of which more than half are 
13:28:42 male, average age was younger, around 40 
years old and again really diverse sample 
13:28:47 when we look at demographics like race and 
ethnicity and diagnosis. Before jumping to 
13:28:52 the data, on the next slide I just wanted to 
share a small caveat around using NCI data 
13:28:59 for advocacy. 
A good analogy is to think about NCI data is 
13:29:03 an exit ramp. 
The data can reveal patterns and trends and 
13:29:07 may point to a few areas where you want to 
look deeper at how your system is working. 
13:29:13 NCI data does not necessarily tell you all 
of the root causes or the right solutions. 
13:29:19 It is not going to give you directions from 
start to finish but it will tell you some 
13:29:25 possible exit ramps to take on your journey 
to quality improvement. Let us take a closer 
13:29:31 look first at who uses self-directed 
supports. You will see here to doughnut 
13:29:36 charts. 
They represent the percent of respondents 
13:29:38 with the NCI-AD survey on the left of the 
screen and the NCI-IDD survey on the right. 
13:29:44 This is the percent were using self-directed 
supports. It is important to note that 
13:29:49 because not every waiver population might be 
sampled to the same extent,
13:29:53  at a state in a given year, this is not 
necessarily a perfect proxy for the extent
13:30:00  of self-direction in a state. 
But at the national level it does give us a 
13:30:05 glimpse of who uses self-direction within 
state-funded LTS as populationsS
13:30:09  populations.

13:30:16  The use of self-directed supports is about 
two times higher in the NCI-AD population at 
13:30:22 around 34% than the NCI-IDD, which is 17% 
nationally.
13:30:25  On the next slide we have a packed circles 
graph.
13:30:28  This is intended to show the use of 
self-directed supports broken down by age 
13:30:34 group. 
Within the NCI-AD and NCI IDD surveys
13:30:36 ,

13:30:38  you see the use of self-direction is lower 
among older respondents
13:30:42 .

13:30:43  We also see that for each age group, the 
use of self-direction is higher
13:30:48  among NCI-AD respondents.

13:30:54  We have sent demographics of people who use 
self-directed supports by race and ethnicity
13:30:59 .

13:30:59  There are a lot of numbers on this table so 
I will just point out a few of the 
13:31:06 similarities and the differences for our two 
surveys that were for Deaf we are focused on 
13:31:12 today. 
For both groups
13:31:13 ...

13:31:15  Lower for Black respondents.

13:31:22  We see differences between the surveys 
however in terms of the use of 
13:31:27 self-direction among white respondents and 
Hispanic respondents. This is a good example 
13:31:31 of why we think we need to think about NCI 
data as an exit ramp
13:31:37  because these numbers show interesting 
patterns but ultimately we need further 
13:31:41 research to really understand the factors 
that contribute to different rates of 
13:31:45 self-direction for different groups. 
The last slide
13:31:48  that I have on demographics shows us the 
difference in the use of self-directed 
13:31:52 supports for those whose preferred means of 
communication is spoken,
13:31:56  and those who use sign language, gestures 
or communication devices to communicate.
13:32:03  I thought this was really interesting to 
see that in both the NCI-AD and the NCI-IDD
13:32:11  there are significantly higher rates of 
self-direction among those who prefer 
13:32:15 non-spoken forms of communication. 
We will come back to this in a bit when we 
13:32:21 look at some of the experiences. 
On the next slide we will turn to
13:32:26  some slides that showcase outcomes related 
to the experience of self-direction.
13:32:32  Here are two tree maps of the responses to 
the question who makes the decisions
13:32:38  about the services that are self-directed?

13:32:41  Ultimately we see that not all people who 
use self-directed supports are making 
13:32:45 decisions about their services,

13:32:47  and from these two tree maps side-by-side, 
we see that that is much more common among
13:32:53  NCI-IDD respondents. 
On the NCI-AD
13:32:57  survey we see 60% of people said they 
mostly make the decisions about the services 
13:33:03 that are self-directed. 
That is the teal box at the top.
13:33:07  On the NCI-IDD just 14%

13:33:09  40% say they mostly make the decisions, 
another
13:33:15  40% say they have family friends help make 
the decision and 46% say
13:33:27  that

13:33:28  someone else decides

13:33:29 . 
.
13:33:30 ..

13:33:34  Differences in how people are expensing 
self-direction in our survey populations
13:33:38 .

13:33:41  On the next slide we have a table showing 
the national data on measures of the 
13:33:47 experience of self-direction.

13:33:48  The good news is that we see relatively 
high rates in both surveys of people saying 
13:33:53 they have enough help deciding how to direct 
their services, that they can make changes 
13:33:59 to their services and that they have the 
amount of control they want over the 
13:34:04 services that are self-directed. 
However, we also see that three quarters of 
13:34:08 NCI-AD respondent say the services and 
supports
13:34:11  they want to self direct are always 
available in about two thirds of NCI-IDD 
13:34:16 respondent say this.

13:34:19  We also see about one third of our NCI-AD 
respondent say they need help with at least 
13:34:25 one part of self-direction like getting 
their staff paid, funding staff, managing 
13:34:30 benefits and this is higher on NCI-IDD with 
about one into respondents.
13:34:34  In this slide we will look at some of these 
outcomes related to the experience of 
13:34:40 self-direction and how those are tied to 
demographics.
13:34:43  We've noticed some rather stark differences 
on both the NCI-IDD and NCI
13:34:47  AD surveys with people who prefer 
non-spoken forms of communication.
13:34:51  We see a pattern that they are a lot less 
likely to have make or
13:34:56  have input on self-direction decisions.

13:34:59  Of all people use on the garage, gestures 
or communication devices, may use family, 
13:35:04 friends and staff to help interpret their 
communication, they should absolutely have 
13:35:09 the same opportunities as their peers to 
make decisions about services. It may be 
13:35:14 there -- additional supports needed to 
facilitate decision-making such as enhanced
13:35:18  training for staff

13:35:19  or updated requirements for individuals who 
helped to develop
13:35:22  person centered centered plan -- patient 
plants.
13:35:28  This slide shows who makes the decisions

13:35:30 ...

13:35:32  Just wanted to spotlight one of the surveys

13:35:35 .

13:35:41  This is a stacked bar graph that shows the 
percent who say they mostly make the 
13:35:46 decisions, that they have input, or that 
someone else makes decisions. One of the 
13:35:51 bars shows that breakdown for those who 
prefer spoken communication. That is the one 
13:35:56 at the top. 
The bottom shows the break down for those 
13:36:00 who prefer non-spoken forms of 
communication. The dark green here shows the 
13:36:05 percent that say they mostly make the 
decisions. 60% for those who use spoken 
13:36:10 communication while just 12% of those who 
prefer non-spoken communication say that 
13:36:14 they mostly make the decisions. 
At the other end of the bar, the yellow,
13:36:19  you see the present who say someone else 
makes the decisions for them is just 13% for 
13:36:25 those who prefer spoken communication, while 
56% for those who prefer non-spoken forms.
13:36:30  It is almost an exact flip. 
I will just finish with a quick look at the 
13:36:36 experience of self-direction by age group on 
the next slide. I was so
13:36:43  somewhat surprised by these results, really 
that they looked so similar across NCI-AD 
13:36:47 and NCI-IDD. 
The green column are those using 
13:36:50 self-directed supports who are 18 through 44.

13:36:53  The teal is 45 through 64.

13:36:55  The gray is 65+ group.

13:37:01  You see both for NCI-AD and NCI-IDD, the 
younger group have lower rates
13:37:06  of saying the services and supports they 
want to self direct are always available.
13:37:12  They have higher rates of saying that they 
need help on at least one part of 
13:37:18 self-direction compared to their older 
peers. We know that there
13:37:25  are long-standing workforce shortages that 
contribute to these numbers but additional 
13:37:29 research is needed to understand the factors 
that contribute to the younger adults having 
13:37:34 a different experience of self-direction so 
we can better plan for the future.
13:37:38  I wanted to plug that we are in the process 
of developing some of these analyses into a 
13:37:45 full issue brief with more information. 
So, stay tuned for that. Thank you.
13:37:50  ALICIA BOEHME: Thank you, hello everyone my 
name is Alicia Boehme.
13:37:54  Christian Moran and I are here to talk 
about the long-term care self-direction 
13:37:58 programs in Wisconsin.

13:38:00  We both work in the division of Medicaid 
Services and oversee different aspects of 
13:38:05 the adult Medicaid long-term care and also 
acute and primary care programs, including 
13:38:09 the programs we are going to be talking 
about today.
13:38:13  Today we will cover

13:38:19  a few topics including the Wisconsin 
long-term care waiver program, landscape in 
13:38:23 Wisconsin. 
The Iver self direction program overview.
13:38:27  How Medicaid collaborates with 
participants, families, advocates, providers 
13:38:30 and partners.

13:38:31  And opportunities to improve growth and 
access to quality
13:38:34 . 
We will also talk about what we wish we knew
13:38:39  when we started the program.

13:38:41  In Wisconsin

13:38:44  we have a number of adult long-term care 
waiver programs
13:38:48 .

13:38:48  All of them cover adults with disabilities 
and older adults.
13:38:55  We know that every state looks different 
but we are here to let you know more about 
13:39:00 the models in Wisconsin. 
Family care, there are about 53,000 
13:39:04 individuals in this program. 
This is our adult long-term care managed 
13:39:08 program.

13:39:10  The second program which is really what we 
will be focusing on a lot today is our IRIS 
13:39:17 program. 
It stands for include, respect, I self 
13:39:20 direct.

13:39:23  This is our self-direction program in 
Wisconsin, we have almost 20,000, 27,000 
13:39:28 individuals in this program. 
The third program we have
13:39:31  programmed in Wisconsin is the partnership 
program.
13:39:33  It has about 3000 individuals.

13:39:41  This is a much smaller program, not 
statewide and covers acute and primary and 
13:39:46 long-term support services in Wisconsin. 
On the right-hand side you can see the NCI-AD
13:39:53  data and you can see that in family care we 
do have a self-direction option.
13:39:59  32% of those in family care choose this 
option.
13:40:02  It allows individuals to self direct

13:40:04  some things in their managed care program

13:40:07  including you can choose some services, 
staff
13:40:10 ,

13:40:10  create their own schedule and set standards

13:40:13  for individuals who are working for them.

13:40:16  This is a small subset and people can choose

13:40:20  if they want

13:40:21  to self direct certain aspects

13:40:23 . 
Secondly,
13:40:26  is the self-direction program which is IRIS

13:40:28 .

13:40:30  This is 99% but hundred percent of these

13:40:34  the individuals

13:40:36  in this program to self direct

13:40:38 .

13:40:49  The history of

13:40:50  the IRIS program

13:40:51 .

13:40:55  It is a fully self-directed program which 
means the participants
13:40:58  have the freedom to decide how they want to 
live their lives.
13:41:03  It was created in 2008

13:41:05  for individuals over the age of 18 years old

13:41:08 . 
Currently, the budget for this program
13:41:11  is about $1 billion

13:41:12 .

13:41:13  This is a very large program

13:41:15 .

13:41:16  IRIS participants

13:41:20  are supported by IRIS consultant agencies, 
we call them ICA
13:41:24 s, and fiscal employment agents or

13:41:26  FDAs

13:41:27 .

13:41:30  Workers and participants are paid through 
the FDA
13:41:33 .

13:41:44  The buyers benefit package includes 
vocational, transportation, supportive 
13:41:47 homecare, personal care

13:41:48 , medical equipment and supplies, counseling 
and therapeutic services.
13:41:51  IRIS participants must have a nursing

13:41:55  home level of care in order to qualify for 
the program
13:41:59 ,

13:41:59  and they receive a budget for long-term 
care services and supports
13:42:03 . 
They manage their monthly budget,
13:42:06  caregiver hiring and their individualized 
program
13:42:08 .

13:42:10  plan

13:42:11 .

13:42:16  This shows the growth of the program which 
has been astronomical. You can see that in 
13:42:22 2008 we started off the program and it has 
consistently increased year-by-year
13:42:26  by significant amounts. 
Now we are
13:42:29  around 27,000 participants in the program

13:42:31 .

13:42:36  This map here on the right hand side

13:42:39  shows

13:42:40  both the F

13:42:41 ea

13:42:41 ea

13:42:43 E

13:42:43 A

13:42:48  and ICA footprints within Wisconsin. 
Individual
13:42:50  have a choice for

13:42:52  FEA

13:42:52 s

13:42:57  and about five ICA's located in different 
parts of the states and regions
13:43:02 . 
The individual's choice depends on the 
13:43:05 region that they are in. 
IRIS
13:43:15  physical employer agencies help 
participants choose and manage the work is 
13:43:19 that Harpo stop and the IRIS consultant 
agencies help participants manage their own 
13:43:23 care and handle the day-to-day program 
operations. We also have
13:43:27  an IRIS self-directed personal care agency 
that we contract with that allows 
13:43:31 participants to hire, train and oversee 
their personal care workers.
13:43:40  We have what we call the IRIS advisory 
committee and they are responsible for 
13:43:45 providing feedback on the program. 
This is very important to the program.
13:43:49  They provide feedback to us on proposed 
changes to program policies, to the 
13:43:54 contracts we have with the various ICASa and 
FEA
13:43:57 s

13:43:57  and also provide input

13:44:00  -- input on federal waivers.

13:44:07  They also provide feedback on reports such 
as NCI
13:44:11  and state led participant satisfaction 
surveys
13:44:13  and implementation of program operations 
and infrastructure
13:44:16 .

13:44:19  The committee members include participants, 
family members, providers, advocacy groups
13:44:25  and whispered that across all three target 
groups
13:44:28  served by the program.

13:44:32  So again, individuals with intellectual 
develop until disabilities, those with 
13:44:36 physical disabilities and older adults. 
To highlight within the context of these 
13:44:40 meetings, we have a public

13:44:44  comment period so anyone is welcome to come 
on and provide feedback to the committee
13:44:49  and to the Department of health services on 
the program.
13:44:54  I will pass it along to Christian Moran who 
will talk more about the IRIS waiver.
13:45:00  CHRISTIAN MORAN:

13:45:05  Thank you, Alicia. 
My name is Christian Moran, I am with the 
13:45:10 Wisconsin division of Medicaid Services. 
Just want to take a few minutes to talk 
13:45:15 about the process we are in and renewing a 
waiver for the self-direction that smacks of 
13:45:20 directed program. 
We operate IRIS under in 1915(C)
13:45:23  waiver and we are very excited with the 
opportunity to make updates to the waiver
13:45:29  as this opportunity only comes around every 
five years.
13:45:35  Our current waiver runs to the end of this 
year, December 31 and the new waiver will be 
13:45:41 effective, sorry, January 1 of next year.

13:45:44  We want to take this opportunity to improve 
the policies and services to make our 
13:45:49 program better and keep it sustainable for 
the 27,000 people who are served by the 
13:45:55 program. 
In the next slide I want to talk briefly 
13:45:58 about our outreach efforts we have done in 
the last year. We began working on our 
13:46:04 waiver in earnest last spring. 
As part of the process we did an extensive 
13:46:09 outreach campaign. 
At the onset we wanted as much as input from 
13:46:13 program participants, families and our 
partners, essentially all of the people 
13:46:17 served by support or have an interest in our 
program. We conducted an online survey. We 
13:46:23 got input our IRIS advisory committee that 
Alicia mentioned as well as our tribal 
13:46:28 health directors. 
We held two virtual public input sessions, 
13:46:31 one in the day and one in the evening. 
Through all of the outreach efforts we 
13:46:37 received over 2100 comments.

13:46:41  In the next slide I want to go over the 
themes we heard as a result of these
13:46:47  this outreach. 
There were six major themes.
13:46:49  The largest proportion of the comments we 
received were about services
13:46:54 , about 40%. 
There was an equal share about
13:46:59  -- with comments about transportation, 
cultural competency and integrity at about 
13:47:03 15% each.

13:47:04  Likewise about housing and self-direction 
at roughly 8%.
13:47:09  While transportation and housing

13:47:10  are

13:47:14  services, we decided to break this out 
separately given how many comments we had 
13:47:19 received about the services.

13:47:21  I will note that many of the comments we

13:47:25  seed were about complex issues that could 
not be addressed solely through the waiver 
13:47:30 itself. 
We have collected all of that input and are 
13:47:34 looking at other ways to address those 
issues outside of the scope of the waiver,
13:47:40  either through policy changes, changes in 
our contracts with their vendors
13:47:44  or other means.

13:47:45  In the slide

13:47:52  the next few slides I will go over some of 
the themes we receive. Again, we received 
13:47:58 many comments about services. 
Just to give you an example of some of the 
13:48:03 contents we received, comments about 
employment
13:48:05  and vocational services, need for that 
employment, training, job training
13:48:11  support with those with disabilities 
looking to enter or stay in the workforce.
13:48:19  I do not have time to read all of the 
comments in the slides but we did want to 
13:48:25 highlight some of the direct feedback we 
received. On each of the slides you will see 
13:48:31 in blue are direct comments that we 
received. I want to highlight a theme of 
13:48:37 transportation. 
We received a significant amount of comments 
13:48:39 around alternative transportation solutions. 
Using for example, Huber and Whiffed lIFT
13:48:44  Lift as a transportation option.

13:48:45  We had our camera care

13:48:49  family care

13:48:53  On the next slide I want to briefly

13:48:56  draw upon some NCI data.

13:48:59  As a point of comparison we have survey 
results
13:49:02  for Wisconsin's 22 1

13:49:04  20

13:49:04 22

13:49:05 -2

13:49:05 0

13:49:06 23

13:49:10  NCI-AD and NCI

13:49:13  IDD for transportation

13:49:14 .

13:49:21  86%

13:49:23  of IRIS participants

13:49:26  compared to 80% for family care

13:49:28 .

13:49:28  By comparison

13:49:30  the table on the right

13:49:36  shows slightly absent for IDD population, 
76%
13:49:41  for IDD population who do not sell direct 
say they have access to transportation
13:49:46  compared to 71% to self direct.

13:49:49  As Lindsay mentioned earlier, we consider 
these results and exit ramp
13:49:53 . 
The results are helpful as we are looking to 
13:49:56 understand differences in how participants 
are experiencing our programs
13:50:00  as we look to explore solutions to close 
these gaps.
13:50:04  In the interest of time,

13:50:07  if we could just briefly go through each of 
these quickly.
13:50:11  You will receive the slides.

13:50:13  The next was touching on cultural 
competency.
13:50:16  The following slide touched upon integrity

13:50:18 .

13:50:21  In the following slide touched upon housing

13:50:23 .

13:50:24  If you have an opportunity

13:50:29  to look the slides you will see some of the 
comments we received from people who 
13:50:35 responded to our outreach efforts. 
With that I will turn it to Alicia for our 
13:50:41 closing slide. 
ALICIA BOEHME:
13:50:42  Thank you, Christian.

13:50:45  In hindsight, as you saw in the previous 
slide that I shared
13:50:50 , the program has grown very quickly and so 
that
13:50:54  has proposed some challenges for us over 
the years
13:50:57  when we created the program we created it 
for a very small number of people
13:51:02 . 
In hindsight we would have built policies 
13:51:05 and program infrastructure differently had 
we known
13:51:08  it was going to be about $1 billion program

13:51:11  with 27,000 individuals as a part of it.

13:51:17  In response to that we have increased our 
internal resources in the IRIS program
13:51:22  over the past couple

13:51:26  number of years will stop we now have a 
larger cross Bureau structure that helps us 
13:51:31 manage the policy, fiscal and oversight 
needed for this large program.
13:51:35  I will pass this along to the next person.

13:51:43  LAURA VEGAS:

13:51:46  Good afternoon, I am Laura Vegas

13:51:48  with the (unknown name) team.

13:51:50  What does it mean for us

13:51:52  and what are some of the takeaways from 
today
13:51:56  in some future directions?

13:51:59  One of the things we learn today is the use 
of self directed supports continues to expand
13:52:05  across all populations that we support in 
the country.
13:52:08  And it is important to ensure that all 
populations have the same opportunity
13:52:13  to find information about and

13:52:15  access self-direction.

13:52:20  As self-direction expands we need to 
measure and monitor the quality of 
13:52:25 self-direction. 
And continued research will be needed to 
13:52:27 explore more deeply

13:52:29  the associations between the use of 
self-direction
13:52:31  and community living outcomes

13:52:33 .

13:52:34  People have been really busy

13:52:36  answering the questions in the chat

13:52:38 .

13:52:39  So, thank you everybody

13:52:42 .

13:52:44  I think that is all we have

13:52:47 . 
Thanks everyone for coming
13:52:48 .

13:52:57  I'm just reading the question. 
A bit about HSRI. They are all about 
13:53:01 improving systems and changing lives. 
They are a nonprofit organization founded in 
13:53:06 1976,

13:53:08  looking to craft community-based, person 
driven solutions across service systems
13:53:11  and they gather research using a 
collaborative, inclusive
13:53:14  and participatory model.

13:53:15  They are a great partner, by the way

13:53:18 .

13:53:18  So, thanks to everyone

13:53:20 .

13:53:22  Are the questions in the chat that we can 
answer?
13:53:26  before...

13:53:29  Or are people taking care of all those? 
LINDSAY DUBOIS: Yes
13:53:32 . 
I saw a question about
13:53:35  kind of self-direction

13:53:36  for people with IDD

13:53:37 ,

13:53:43  data on states that are supporting people 
to self-correct even when they have high 
13:53:48 support needs like 24/7 support. 
With the NCI data we can look at that.
13:53:53  We do have questions on the extent of 
supports
13:53:56  required and we can look at self-direction 
for folks
13:53:59 .

13:54:00  And then in terms of comparisons to spending

13:54:03 ...

13:54:03  Laura or Molly

13:54:08  (indiscernible) if there is any data you 
are familiar with
13:54:11  that could make that connection to state 
budgets
13:54:14  related to self-direction?

13:54:18  MOLLY MORRIS: This is Molly.

13:54:20  I do not have access to that budget 
information
13:54:23  but I would love to have access to it 
(Laughs)
13:54:27  I want to know that story as well.

13:54:30  I also just wanted to jump in on the other 
question
13:54:34  where the person was asking about what is

13:54:37  Deaf what is up direction look

13:54:39  like for people with

13:54:41  IDD when their parents H out from being in 
a caregiver role?
13:54:46  I want to acknowledge what an important

13:55:02 ..

13:55:03 .

13:55:05  Interesting solutions to that problem

13:55:07  but it will also require innovation.

13:55:14  LAURA VEGAS:

13:55:18  Any other questions that are not being 
answered in the chat?
13:55:22  Molly, there is one more question for you.

13:55:25  It says we hope you can help us learn about 
aging in place,
13:55:29  about 24/7 supports

13:55:31  and Applied Self-Direction

13:55:32  can truly be helpful

13:55:34 .

13:55:34  MOLLY MORRIS:

13:55:36  Thank you, Maggie

13:55:37 .

13:55:39  I know who you are and I appreciate that 
comment and I will just say
13:55:45 , as a sibling of someone with IDD,

13:55:48  this particular issues close to my heart.

13:55:50  LAURA VEGAS: Someone asked if the

13:55:58  (indiscernible) is the independent facility 
or like a sport broker? Also where is it 
13:56:03 required in statute to the previous 
question? Anyone want to take that one?
13:56:08  Is an independent facility or like a 
support broker?
13:56:12  VAL BRADLEY:

13:56:19  What the function of independent -- the 
function of an independent facilitator is 
13:56:23 our CMS's

13:56:26  definition of self direction. 
If the state is doing self direction they 
13:56:30 have to provide independent facilitation. 
States vary in terms of how they 
13:56:35 operationalize independent facilitation.

13:56:38  That could be through contract and support 
brokers, it could be through the state or a 
13:56:44 case manager. 
It could also in some states be through a 
13:56:48 contracted staff person or personal agent 
who can serve that function. Our friends from
13:56:53  Wisconsin and Molly may have other answers 
to that question.
13:56:58  MOLLY MORRIS:

13:57:02  I was a bit distracted looking at all of 
these inputs (Laughs)
13:57:06  people asking question.

13:57:10  I will just reiterate, forgive me if I am 
repeating anything Val said, nationally,
13:57:18  every state structures their programs 
differently. Information and assistance is a 
13:57:22 broad category of support that is different 
from a case manager that is their job, 
13:57:27 coaching you to be an employer. 
That looks and is called and is structured 
13:57:32 in different ways state to state.

13:57:34  LAURA VEGAS: Thank you, Molly. 
There were some comments and questions about 
13:57:39 oversight. 
The FSA
13:57:45  and states, I am wondering if Wisconsin, 
since we have a few minutes, would mind 
13:57:51 speaking to how they provide oversight of 
their self-directed work and ensure the 
13:57:55 services are quality? 
ALICIA BOEHME: This is Alicia again. Yes, we 
13:57:59 have a whole team that ensures that our 
contracted entities, the FEA
13:58:04 s ,, the ICAs

13:58:08  and (unknown name) are meeting the 
expectations of the contract
13:58:11 .

13:58:13  If they are not we work with them and we 
also have a team to help solve problems
13:58:20  where participants might be having 
disagreements with
13:58:22  the program or concerns about the program.

13:58:25  We also step in to make sure that those are 
resolved
13:58:29 , and work with our contracted entities to 
do that.
13:58:33  If the contracted entity is not meeting the 
expectations of the contract
13:58:38  or there are major concerns, then we can 
hold them accountable
13:58:42  through corrective action plan and that is 
one tool that we use
13:58:50 .

13:58:50  There is sanctions if we

13:58:56  choose to implement them. 
But we like to have a collaborative working 
13:59:00 relationship with all of our contractors and 
work with them to make sure that 
13:59:05 improvements are made. 
LAURA VEGAS: Thank you. Thanks to everyone 
13:59:08 and to our state panel. 
I always learn a lot
13:59:12  on these panels.

13:59:14  You will see on your screen a post webinar

13:59:20  evaluation. 
Please let us know how we did. We are always 
13:59:24 a need for feedback to constantly

13:59:26  improve the work that we do and resources 
we provide. Have a great afternoon.
13:59:31  We appreciate your purchase a patient and 
active conversation in the question and 
13:59:36 answers. 
Thanks.
13:59:48  (

13:59:48 End

13:59:48  of w

13:59:49 ebinar

13:59:50 )