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Task Force Minutes Task Force to Study the DDA Rate Payment Systems


Task Force Minutes Task Force to Study the DDA Rate Payment Systems

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									Minutes for Task Force Meeting
Date: March 10, 2008
Time: 1:00 p.m. – 4:00 p.m.

Meeting called to order at 1:10 p.m.

Review of Minutes from 2.11.07

      Board of Nursing Corrections (Ted Giovannis wanted to verify that BON did not reply to
       his questionAudrey or Jim, any way you want to address?
      Approved minutes from February 11, 2008

Supported Employme nt
Ms. Cathy Lyle (see pink handout)
Mr. Johnson
    Is there a cost differential?
    Ms. Lyle’s response: Yes, there is a different intensity for each type of job a consumer
       looks for.
    Should the actual identification of job be a grant process, rather than a daily cost
Mr. Adkins
    The cost at the beginning versus later down the line when looking for a job
    Recently had to turn down an individual who needs a one to one to find a job and needs a
       one to one job coach
    Need to hire for individuals for job coaches
    Once individual is employed and fairly self-sufficient, individual needs a lot less supports
           o Provider is then paid every day, even though consumer is employer
    Key is at beginning of finding job
    The MOU between DDA and the Division of Rehabilitation Services should be re-
    Has individuals in workshop settings; takes a lot of money to find them jobs in
           o Some individuals benefit greatly from segregated day settings
           o Some job coaches actually do the job when they go with individual in community

Mr. Lovell
    Transportation is problematic b/c of different kinds of employment
    Individual may have employer separate from provider
    Different settings get different funding
    Most providers would like to see employers employ consumers and the provider provide
      the supports
    Time is an issue: many consumers in a part-time employment; can be good or bad

      Transportation to the supported employment is an issue
           o Need access to public transportation
           o Need provider to transport them to job
      Public school system issue: job training was provided at public school system
           o Does not transition when the individual ages out
      Should look at difference between rehabilitation services and DDA memorandum
      We are all strong advocates for individuals to have employment in community, but
       realistic that not everyone can get employment in community
      Need to work long hours

Ms. Mills
    In past, Ms. Mills received supports from a workshop setting
          o 7 years
          o Did not feel agency provided any supports
          o Individuals were plopped into her workshop setting, still there after 20 years
          o Should know what is out in community
    Another individual: receives supports
          o Has position out in community
          o Very happy
          o Old Management happy with individual
          o New management trying to get individual out slowly
    One person once came home with 11 cent paycheck: was cost of paper for paycheck and
      transportation worth her goingresponse to Mr. Adkins regarding segregated settings
    Why aren’t programs finding something for individuals to do in community to get

Mr. Schnorf
    No statistics, but appears to be large turnover

Ms. Lyle
      Would grant be performance based?

Del. Montgomery
     Funding of grants may be difficult
     Continuous re-application
     May lose funding

Mr. Giovannis
    Would a grant be lost over time?
    Could you make it part of the base? Not an augmentation grant

Ms. Waters
    Augmentation grants no longer exists; add-ons instead
    More of a contract that would be available year-to-year

Mr. Schulz
    SE model is good
    Billing is rigid and biggest problem

Ms. Mulazim
    Her agency does not provide SE
    Offer similar to Ms. Mills situation about workshop setting

Public Testimony on Supported Employment
MACS Testimony (Karen Lee, SEEC & Alliance)
   Has worked in SE for a long time; both federally and regionally
   Federal govt. is moving away from RSA (DORS) towards labor/workforce investment
   SE model: only pay for someone who works 4 hours/day
   25% job development; 75% getting to know/following upthe worse the match, more
   Customized employment: match the job better to individual
        o More technical assistance
        o Insurgence of information
        o Combo of day habilitation and SE
        o Empowers individuals with DD to get out of poverty
   Not sure of MD’s ranking in SE
   Current funding is too restrictive (use day rehab for SE for funding)
   Not under funding regulations, SE under other regulations
   Disconnect in DDA rates
   Current annual SE rate is divided over 7 days not 5
        o Some funds not making it to provider

     Do not have workshop setting
     Almost everyone in community
     Difficult under current system
     23 employment specialist (a few years ago); currently 12; with same number of
       consumerstherefore, caseload is higher
     Job placement is lengthy process
     Grossly underfunded; direct care is about $1.00, but pay job coaches about $13/hour
          o Individual must be flexible and have many skills
          o Higher expertise

      Transportation cost is about 1/3 of cost; just visiting employers and sites is largest
       expense and not paid for
           o Reimbursement is based on shelter workshop, not real community placement
      Paid by the day: if individual works 3 days, get 3; not 5; part-time work is almost
       preferred; results in fraction of funding
      Contrast with MHA model; all individuals get same rate, not based on days worked
      Doors situation: immediately placed on waiting list; supposed to be paying for job
       development; reduction in funds; not getting SE funding through Doors
      6-8 months waiting list

Ms. Lyle:
    Part-time: what do they do if they don’t go to workshop?
    Answer: they choose to work only a few days; they do not go to a day program; might go
       to community activities
           o One individual worked 3 days a week at 3hours a daycould not bill
    Answer (Karen Lee): stamina issues
           o Some individuals can only work a few hours a day
           o Possible discrimination issue b/c some consumers cannot work 4 hours/day

Public Testimony on Self-Direction

Michael Bloom: See handout

Barbara Moore
    Choose own staff
    Budget; fiscal management service
    List of what is spent; budget to train staff
    Meeting once a month with her team to discuss her situation: goals, health, etc.
    I am well-respected and have self- worth
    Anyone who can should be allowed to be in self direction
    Yes, can switch my budget around
          o Ex.: Meeting last Monday
          o $$ was not being utilized
          o Insurance for support staff to go horse back riding
          o One staff for several months
          o Previous provider had a lot of staff turnover
    Ms. Mills: has similar situation but not with New Directions
          o Have to be approved by DDA
          o Categories for $$$
          o Is New Directions the same? Yes

Ken Capone
    Public Policy Coordinator for People on the Go

      Some members on Community Pathways waiver; want to change to New
       Directionshave better self direction with New Directions
      Can choose living situation, staff, etc.
      Decrease in quarterly meetings b/c of transportation issues
      Urge to consider expanding New Directions
      Remove financial barriers to self direction
      Need as much independence as possible
      Ms. Mills: heard same as Kenny that transportation is unavailable for those wanting to go
       to the quarterly meetings

Committee Discussion on Self-Direction
Mr. Schulz
    Barriers: FPS or CSLA
    Two people of different funding stream cannot live togethershould be able to find a
       way to do so
    Greater independence costs more to support
    Absurd situation that individuals want to marry but need a roommate
    Acknowledging that this is more expensive

Mr. Adkins
    Disagrees with Mr. Schulzdoes not have to be more expensive
    Two consumers with different funding streams: residential funding for one was switched
      to CSLA; will cost less; savings of $30-40K
    Can go the other way too

Ms. Mills
    Not more expensive to support out in the community b/c each individual has their own
      set of $$ (budget) from DDA
    My $$ is less b/c I need less supports
    Not more cost
    Married couple (Mr. Schulz): I believe it may have to do with Section 8 and SSI;
      combined income for couple

Ms. Lyle
    Back to Mr. Shulz about residential and CSLA consumers living together? Is that a
    Ms. Waters: yes, b/c streams are separate. But can convert to change residential to CSLA
    Mr. Johnson: model that was developed incorporates more than 1-2 people living

Ms. Mulazim
    Similar situation: married couple were able to reduce their funding, savings b/c switch
      funding stream

Mr. Giovannis

      How does an individual’s budget get developed? Can it change?
      Ms. Waters:
           o Matrix score
           o Funding associated
           o Provider and individual consumer discuss options
           o CSLA is similar (except consumer is living at home with supports)
    Mr. Lovell: matrix score is fixed (for residential, SE, and day)
           o CSLA has more flexibility b/c based on hours served
           o Regulatory process/waiver: could we more flexible in our system so that funding
              streams are not so rigid?
Rick Callahan (ARC of Central Chesapeake)
    Budget development for self-direction
    Person directed process
    Line item budget
    Can move $$ around as long as DDA approves
    Hardest part of moving $$ around is between Medicaid funding and things such as food
    Arc of Chesapeake is one of two fiscal managers in MD
    Mr. Romans: how do you determine $$?
           o Answer: Self-direction is based on needs and team assessment
           o Risk pool for emergency services
           o Most consumers seem to stay within budget
    Mr. Johnson: you are just fiscal managers
           o Answer: yes
           o Individuals are their own employers


Ms. Mulazim
    40-82 hours of service (on average); most do not receive awake-overnight
    Consumers seem to more independent and less court involved
    Some like staff, some do notmore flexible model and can get new staff if wanted

Public Testimony on CSLA

Tim Weins (Jubilee)
    See handout
    100 individual: 50% in residential; 50% in CSLA; all in Montgomery County
    CSLA in less need of fixing; not as underfunded
    Overview of CSLA
         o More hours provide; less money you get
         o More people that live together, the better for provider b/c of hours
    DDA began auditing: there is justification
         o However, not viable system
         o Example:

                     MAPS MD does audit
                     Chose 10 of clients served out of 50
                     Of 10, over in some and under in some
                     Ended up providing more hours overall but b/c of fewer hours for those
                      few consumerslikely to lose money
                   Not much of incentive to reduce hours b/c of risk management
                   More flexibility for overall hours of service provided
                   Still have individual accountability (i.e. switch providers)
                   Resource coordinators, licensing, oversight
          o   Mr. Schulz: Piggy-backing on Mr. Weins comments about total overall hours.
              Similar to residential, should not be counted against provider if can provide
              appropriate hours, overlapping hours. One-sided approach; resource driven; cost-
              containment issues. Legislative audit requirements: should check. Very rigid.
          o   Mr. Schnorf: Is there flexibility in CSLA system (of needing 3 individuals)?
              Answer: Yes, some. No barrier, but need to go back to DDA. $$ is usually only
              for crises. If reduction in number of individuals is crisis, might be able to do it.
          o   Mr. Schnorf: If clients need 2 hours each and live together, why should it be
              counted as 4 instead of 2? Answer: B/c client hours overlap, counts against
              provider (not always, but often).
          o   Ms. Mills: If staff person is there for 2 individuals, whose budget does it come out
              of? Answer: both.
Rick Callahan
    Housing
           o 211 individuals (87 in CSLA)
           o Housing was standardized when CSLA began: standard no longer being applied
              in today’s market
           o CSLA is most self-directed model, outside of New Directions
           o Depending on region, may or may not get housing
                    Get 1/3 of rent per individual
           o Proposing to go back to HUD guidelines; no need for new system
           o Biggest barrier for CSLA is housing cost
           o Ms. Lyle: Do HUD guidelines include food? Answer: Housing does not include
              food, but does include utilities
           o Mr. Lovell: What would you recommend? Answer: HUD is ok, but need
              discussion around food costs; food stamps are not even close
    Nursing
           o Additional mandates increase costs
           o CSLA, at first, did not have nursing costs included in plans
           o Population is aging
           o Current professional rate is $26/hour
           o Unclear if nursing is in the rate
           o Almost impossible to get hours PLUS nursing services; should be a supplemental
           o Health risk screening tool: to assess nursing needs
                    Unsure as to acuity of tool
           o Could use Medicaid rate for reimbursement
    Something needs to be built in for escalating costs

      Mr. Schulz: do you think health screening tool can lower costs? Answer: Yes.

Mr. Lovell: Service Funding Plans
    If DDA provides housing in CSLA budget, is that state funding?
    Yes, because Medicaid does not reimburse for housing.
    Does it make sense to look at cost of care and adjust to CSLA?
           o Answer: CSLA does not have cost of care, but not sure.
Mr. Giovannis: Cost- neutral.
    Ms. Waters: CSLA is not a facility-based model
           o Looks at plan and numbers of hours in plan

Rick Callahan: Might be cost-neutral, but not necessarily with federal match $$.
    Greater flexibility in ???

Other Business
Mr. Johnson
    Next meeting
          o Rough draft of suggested recommendations
          o FPS Matrix discussion
          o Cost of Living Adjustments
          o Add-ons

Future Meetings

Wednesday, April 16, 2008 at 10:00 a.m. in Columbia, Owen Brown Interfaith Center (email to
follow with address)


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