NADD U.S. Policy Update (from the NADD Bulletin Volume XII Number 1)

Complete listing

Transforming Missouri's System for People with Developmental Disabilities

Robin Rust

A challenge faced by policy planners in the field of developmental disabilities (DD) is how to continue the progress toward full inclusion in a time of state budget crisis and retool the system to address emerging issues for people with a dual diagnosis of DD and mental illness (MI).

The Missouri Division of Developmental Disabilities is engaged in systems change that will result in a service continuum better balanced toward home and community-based services versus congregate living arrangements, with improved quality oversight.

Eleven DD Regional Offices located throughout Missouri are the primary entry points into the system, providing eligibility determination, assessment and service coordination.   In recent years, caseloads have increased to levels far in excess of standard best practice of 1:40.   Feedback from stakeholders has recommended that caseloads be reduced, and that there be more local control and decision making.  To accomplish this, the division is partnering with county boards for developmental disabilities to increase service coordinators statewide.    Local funds may be used to match federal Medicaid funding through the targeted case management state Medicaid plan option and in Missouri's three 1915(c) home and community-based waivers for developmental disabilities.   As of late 2008, 31 counties have entered into agreements with the division to provide service coordination, which has provided additional revenue to the state resulting in increased capacity to meet the needs of Missourians with developmental disabilities.

Missouri is progressing toward a reduction in numbers of people residing in state operated habilitation centers.   Facility census has declined from over 1200 in 2003 to fewer than 850 as of late 2008.   The role of the state facilities is evolving away from long-term residential care toward a short term crisis stabilization service, due to lack of capacity of both private and public inpatient psychiatric hospitals.

An emerging issue is an increase in the number of individuals who have a dual diagnosis of DD/MI.  While it is estimated that 20% or more of the individuals yet to transition from habilitation centers have a dual diagnosis, the greater proportion of the total population eligible for division services are reflected in the numbers of new people, including both children and older adults, seeking to enter the developmental disabilities system for the first time, who are already in the community and wish to remain there. 

The division is implementing a multi-faceted approach to address these challenges, by improving the person-centered planning process, more effective assessment of risk factors during planning, improved protocols for crisis planning and prevention, by increasing the capacity for mobile crisis intervention, and developing short term crisis stabilization beds in state operated ICF DD facilities.

To increase the skills pertaining to assessment of risk, a training program for service coordinators was developed.  The training covers risk assessment and identification, integration of risk assessment into person-centered planning, development of strategies to address risk, and new directions in risk assessment.   In addition, a protocol and checklist for monitoring how effectively service coordinators assess risk was developed.  The protocol will facilitate the transition from direct provision of service coordination by state staff to the oversight of service coordination provided by county boards for developmental disabilities and other organizations.

The division is implementing strategies to change the culture within the system from previous philosophies and theories on behavior, usually called behavior management, to positive behavioral support, or PBS, which is grounded in respect for the individual, positive outcomes for people, and current best practice standards.  PBS is a guiding philosophy for providing services and supports for all people who have developmental disabilities, including those with challenging behaviors.  A PBS "train the trainer" initiative is underway, with a goal of increasing the capacity within the private provider community for the training of direct support professionals in PBS principals and strategies.

As service coordination capacity is increased in county DD boards, it is anticipated that Regional Office resources can be redeployed from service coordination to behavior resource teams, including mobile crisis teams, to respond to the needs of people in the community.    Methods of engaging the private provider network to build local capacity to provide crisis prevention and intervention for people receiving residential supports and services are being explored.   To facilitate the development of a cross-systems network of crisis planning, prevention and intervention, the Missouri Division of Developmental Disabilities is enlisting the expertise of Dr. Joan Beasley.   A series of training events and workshops is planned, targeted to staff in state-operated crisis units, the DD Regional Offices, and the private provider community.

When implementing significant systems transformation initiatives, policy planners should consider a multi-pronged approach, including building upon and enhancing existing partnerships, enlisting technical assistance from experts, listening to and acting on stakeholder input, and finding creating ways to strengthen and/or retool capacity that already exists within the system.

For more information please contact Robin Rust, Project Director, DD Systems Transformation at:


The "U.S. Public Policy Update" is an ongoing column in the NADD Bulletin.  We welcome your comments and submissions for this column.  To learn more or to contribute to this column, you may contact Joan Beasley, Editor of the U.S. Public Policy Update at