Disability » Christiaan's Perspective

Looking Back (Part 6)

Jun 212011

Perhaps one of the most entertaining developments in waiver history was the creation of IPMG’s “Insync” provider selection tool. The purpose of this was to allow consumers to review provider qualifications and make a decision without consulting the long provider-list that offered no real information about providers. It also promised to connect providers with consumers by showing consumers which providers wanted to serve them.

The actual product, a generic database product from Intuit, left much to be desired. The Insync system managed to give providers almost no information at all about the consumer (confidentiality) while asking the provider to indicate how interested they are in providing services. This is done, literally, by rating their interest on a scale from “not interested” through “very interested”. A common joke among providers is openly wondering how many referrals a provider would get if they were “somewhat interested” in serving an individual. The Insync system lost much of its support when providers found out that if there was not a minimum number of interested providers, the system was scrapped and the pick-list was used. Regardless, providers must use whatever tools are available, so Insync is still monitored on a daily basis, even though (in my area) there have been no consumers listed in months.

There was quite a bit of concern in the provider community at the beginning of 2008. In spite of the assurance that stakeholder input would be a key component of the development of the new waiver system, the absence of information was so profound that the rumor mill took over. Providers began sending people to provider meetings in the “pilot” regions of the state. Any gap in information was quickly filled by speculation. Families were terrified that services that they depended upon would be gone forever. When they called their local ARC affiliates for information, they were told that there was no information to give.

A letter was released by the DDRS director in the middle of this confusion, to assure families and providers who were concerned that sheltered work was being limited that this was not the case. The letter expressed anger at providers for creating this rumor, openly accusing them of inventing it to frighten families. The self-congratulatory letter also reminded the recipients that DDRS was completely open and inclusive of ideas from stakeholders. Finally, it listed mutual accomplishments that included the creation of a DSP training program, crisis services, outreach services, and improvements to the case management system. As of this posting, all of these accomplishments have been eliminated.

In September of 2008, after many cost reports, questions, and revisions, the Day Services definitions and rates were released. Originally, the state wished to use the same methodology for day services as it did for residential- using the staff hour as the unit of reimbursement, with the cost split between all consumers present with the DSP at the time of the billing. Providers objected, as such a system would reduce consumer choice by forcing all consumers in a group to stay with that group. The state responded by dividing the staff/hour unit of service into discrete, ratio-based units of service. This greatly increased the consumers’ ability to choose different activities and services, but required providers to track ratios every 15 minutes to determine the appropriate billing code. The increased documentation and tracking required to verify that a service was appropriately billed let to significant cost increases in providing the service.

2009 Marked the official launch of the short-lived OASIS program. From the moment that the first allocations were released, it was apparent that something was very, very wrong. The “black box,” or secret formula for assigning dollars based on consumer need seemed to be operating on an entirely different wavelength than what was expected by families, providers, and even employees of the state. Large swings were noted, awarding huge increases in authorizations to people who did not need them and cutting services to individuals who could not safely live with such a reduction. After a few weeks of embarrassing anecdotes from families and heartfelt letters from providers and advocates, OASIS was frozen by the secretary of FSSA, pending investigation into the methodology of the allocation method. March or 2009 locked in authorizations at the previous year’s amounts, but continued to roll forward with the Uniform Rate Methodology that was based on the OASIS allocation method. The result was a hybrid of old allocations and new ways to bill services. In short, it was a system that would limp along until something better came along.

“Something better” did not come along for quite a while. The complications of uniform rate methodology and ratio-based billing added significant costs to service delivery, while the revenue side of the equation remained in limbo. Agencies, Families, and consumers agreed then, as now, that there must be an objective system for allocating resources. Even with all of the challenges to date, there is no other rational solution. A transparent, logical, and reliable system that is understood and held valid by all stakeholders is certainly worth the wait for its development.

And wait we did. There has been any number of advisory panels and work groups called in by DDRS to develop such a system. Candid feedback was requested and freely given. Providers and consumers met together at agencies to brainstorm and develop ideas, and these were sent to advisors to be discussed at DDRS forums. It appeared that this was going to be a mutually agreed upon plan that worked for the state, for consumers, and providers alike.

Part 7 will draw this history to a close and describe the current state of the Waiver. Until then…

Looking Back (Part 5)

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Mar 232011

While the history of the Indiana waiver system may seem chaotic and poorly thought out so far, the first portion of this history cannot hold a candle to the difficulties encountered from 2007 through now. It is in this flurry of events when consumers and providers were introduced to terms such as “ICAP,” “IPMG,” and “OASIS.”

In January, 2007, it was announced that an ICAP (Inventory for Client and Agency Planning) assessment would be given to each individual to determine an objective level of need. This would be given to 10,000 individuals during a pilot phase by Arbitre Consulting- A company contracted by Indiana to handle this massive project.

Meantime, January marked a change in residential and day services billing. The state, realizing that the system of paying providers regardless of whether or not services were provided would be causing them enormous difficulty with CMS, attempted to correct the problem by only allowing for billing on attendance days. While very tempting to providers to remind BDDS of their original concerns, most providers put most of their effort into putting together enough information to determine attendance patterns and retooling (again) to the latest model. As simply cutting revenue amounts to providers would close programs state-wide, “absenteeism factors” and other band-aids were applied to allow services to continue while a true objective allocation system and true uniform rates were developed.

Mid-2007 saw the launch of the “Pilot Project” for OASIS (the system to replace the current system with an objective method of allocation) in part of the state. Information meetings with Davis-Deshaies, Arbitre, and DDRS were scheduled to answer questions about the project. Providers meetings were scheduled separate from Family/Consumer meetings. Providers were also informed that they would be given several forms to collect cost information. As there was growing concern over the accuracy of the ICAP assessments, a helpline was developed to address these concerns as they came up.

In a May, 2007 memo, it was announced that CMS would allow a gradual phase-in of the OASIS model, with the pilot complete in 2008 and full implementation by mid-2009. This same memo also stated, for the first time, a promise that most providers and families have considered to be disingenuous at best: “Significant emphasis will be placed on gathering stakeholder input and creating a rate model and individual budget process that meet the needs of the people we serve and the providers that serve them.” It is this statement, along with the state’s refusal to disclose the mechanism for how allocations are determined, that has been central to the friction during the last few years.

From May until July, there was a flurry of confused activity. There was a rush to meet the original deadlines that were promised to CMS, and as a result, many corners were cut. A memo was sent out changing the due date for cost reports, immediately followed by one acknowledging an error in those cost reports. A policy bulletin reversed a previous memo, now stating that camp registration was not covered under waiver, but staff time was. Finally, all providers were asked to submit their most recent audited financial statements.

Finally, the rates that would be utilized for the pilot programs were released toward the end of the year. The Pilot would officially begin on January 1, 2008, for district 4 consumers. This was limited to residential, respite, and behavioral supports as well as adult foster care. Other services would begin in March. The rates, as well as the way that services were to be documented and billed were altogether new. While providers were apprehensive, assurances that everything would be subject to review based on the pilot program results made most willing to “wait and see” instead of passing judgment on the new program.

Although we did not make it to OBA in this post, my intent is to keep these sections as short and readable as I can. Part 6 will discuss the rise and fall of OASIS and uniform rate methodology. The final section will bring the history to a close as we begin talking in present tense.

Looking Back (Part 4)

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Feb 262011

Things were quiet for the first part of 2003. After the flurry of activity surrounding the waiver, case management, waiting lists, and protocols, it was a welcome break in the action. Things were certainly complicated. The tendency to clarify and re-clarify how services should be provided and billed added several layers of documentation to the process, and administrative support staff were added at most agencies to pull together the information needed to assure compliance. The cost of providing services through the waiver was going up.

Case Management was getting to be a very challenging program to operate. As the “hub” of the service wheel, it was determined that all case managers required provider numbers to bill for their services. Providers, very new to the Medicaid model, were given detailed instructions on how to bring their case managers into compliance with the new system. As case management was a critical service component, dutifully filled out the forms, reorganized, and assured that their case managers were fully trained to comply with all of the new requirements. It was important to do so, because having case management on site assured that there was a quick response to changing consumer needs. Providers heard anecdotally that so-called “Outside” case managers did not know the consumers well, and were slow to act when service changes were requested.

By 2004, it was clear that things were changing again. The numbers were in, and in spite of regular pressure to reduce costs, the added paperwork and infrastructure continued to increase costs. Providers were aggressively defending the rates they were paid, as with each added clarification from the state, expense was added for providers. CETA was eliminated altogether, and Community based individual habilitation, once the preferred service by the state under title XX, was capped at 25 hours per month.

In Mid-2004, the State announced that providers of residential services could no longer be case managers. This was a devastating prospect to providers, as all of the time and expense of hiring and training a competent case management department was wasted. Many providers, including my agency, decided to maintain their employees as internal coordinators, knowing that an outside entity could not deliver the level of service that our consumers had come to expect. This choice proved to be a good one, as the next generation of case managers (with a few notable exceptions) absolutely failed to meet consumer needs.

The term “matrix” came into use on a regular basis, with the idea of using an objective method to determine how services are authorized. Providers were (and still are) in favor of this, and were excited about the possibility of working together to develop the tools to make this concept a reality. The implementation date for “matrix” was set for June of 2005. For providers, this year of waiting for matrix was one of the most difficult we had faced. Regular communications from the state added documentation requirements and decreased revenue steadily. The Outside Case Managers were every bit as slow to respond as anticipated, and things like 15 minute documentation made service delivery an administrative nightmare. Staff were re-deployed with time built in where they were not serving consumers, so that they could complete the paperwork each day.

Of course, the launch-date in 2005 was missed, with Matrix still in the planning stages. An independent firm, called Arbitre, was employed to develop and implement an assessment tool (called ICAP) starting with residents of the Fort Wayne Developmental Center. Many an eyebrow was raised when a psychologist researched the ICAP tool and found it an unreliable assessment, but the state could not be dissuaded from using it.

This issue was moot by August 2005, however, because the governor announced a new system, called “annual contract” that would reduce the administrative burden. The Governor stated that things like 15 minute recording was an “administrative nightmare.” David Gootee was hired to manage the transition to this system.

Providers were very concerned about the annual plan model. First, it combined many elements that were separately billable into a single rate. Providers that had, for example, hired an extensive nursing staff to provide healthcare coordination, found themselves with staff that were no longer reimbursable. They became “the cost of doing business.” Also, there was an obvious problem with the blending of many services into one rate- providers would no longer be able to show the connection between service delivery and outcomes, a known CMS issue.

These concerns fell on deaf ears, however, and the annual contract plan launched- without the matrix tool, and without a way for providers to justify service levels. Most providers continued to document services in units, because we were sure that this information would be demanded once the annual rate idea fell out of favor. Again, we were right.

And so began the per diem billing methodology, and the changing of the service model to meet the new service definition. This model was stable for a while, and in spite of our fears, providers changed almost every aspect of service delivery to meet the requirements of the new model.

The Per Diem billing was in place for a while, and things began to look up- like there may be a stable period to focus on best practices.

Next time, we will discuss the fall of the per diem, the reestablishment of 15 minute units, OASIS, and finally OBA. Talk to you then…

Looking Back (Part III)

Professional 1 Response »

Jan 232011

By May of 2002, it was obvious that there was a problem with the waiver. The administration had been sure that people would flock to the new waivers in droves, once the new services were announced. They were wrong.

The existing system was simple and easy to understand. There were services that consumers needed, and they were delivered by providers that were funded by the state. The waiver was a different animal altogether. As both providers and state officials tried to explain the new system, the message got buried in the complexity. Families preferred not to know the details- only that their loved one was taken care of and happy.

Memos to providers from the state began to get more desperate. Providers were told that funding was in jeopardy. They were told that if they did not convince families to move to the waiver, they would not be paid for the services they provided. Families were informed that the current system rarely provided more service than Medicaid waiver, and that the move to waiver would give them more flexibility and would be easier. My agency, like many others, held meetings with families to discuss the benefits of the waiver program. Believing that the complexity of the system was a necessary side effect of more robust services, many providers backed the new system.

We backed it because it was a promise of stability. For years, we had struggled with the fact that when the state ran out of funds, providers were not paid. We also knew that there were many people that could not access services. Logically, if the state went from a system where it paid for everything to a system where the federal government paid for most of it, many more people would have access to the services they so desperately needed.

The next few months were a flurry of changes that I cannot wrap my head around, even with the memos in front of me. Rates were changed, several “clarifying” memos were sent out, and the language and tone of the communications from the state became almost threatening. The State was in trouble, and the federal government was taking a keen interest in Indiana affairs.

By October of 2002, providers were being informed that since state funded services were to be accessed only if there were no other funding sources available, to NOT convert an individual to the Medicaid Waiver could be considered fraud.

The waiver had become something that was not a choice, but a system that was critical to the survival of the supports that families depended upon. Provider agencies became expert in Medicaid waiver procedures, and the case managers employed by the agencies became expert in determining eligibility and navigating the juggernaut that was the Indiana Waiver Program.

At the end of the year, discussions began on identifying ways to simplify services. The director of the Bureau of Developmental Disabilities Services began talking about services being paid on a “Daily Rate” where providers were held accountable for assuring that needs were met, but no longer were bound to a specific authorization.

Part Four is in the works…

Looking Back (Part 2)

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Dec 302010

The Medicaid Waiver began to be a topic of discussion after I had been at my post for about six months. Seemingly out of the blue (from my prospective) there was a flurry of trainings, memos, and requirements that meant changing a lot of our job descriptions, programming, and systems. Prior to this time, the biggest discussion topic for providers was the 317 Plan, which paved the way for community based services and the closure of institutional settings.

One of the most interesting changes was the institution of Targeted Case Management. Under the waiver that was submitted, provider agencies with qualified staff (QMRP) were authorized to be case managers for people transitioning to the waiver. The authorization process, budgeting, and coordination of services was very complicated and time consuming, but it was also a reimbursable service. Additionally, Health Care Coordination and Transportation were to be added for agencies with qualified staff. Providers were encouraged to begin the process and convert as many individuals to the waiver as possible. A memo from the state in early October, 2001, confirmed that the waiver was approved with the new services.

As most agencies used QMRP-D (designee) individuals in social services, this would require some reorganization and potentially hiring staff who met the TCM certification requirements. A reimbursement rate increase of 9% for staff training, wages, and benefits was anticipated after negotiations with the state- an increase desperately needed to fund the increases in staffing and administrative burden that came with the new waiver.

In November of 2001, a memo from the director of the Fiscal Division filled in some blanks. First, it clarified that, in addition to the regular Medicaid hurdles, eligibility would be determined by a Developmental Disabilities Profile (DDP) of which IQ score was one of many factors. The DDP minimum score to show eligibility was set at 35. While agencies were asked to collect all of the necessary data, including DDP, the official eligibility determination could only be made by the Office of Medicaid Policy. Once found eligible, the Fiscal Division would review the proposed budget and make the final approval decision. Case managers were warned that any budget cannot cost more than ICF/MR. The memo encouraged cost-effectiveness, and suggested reminding families that savings here would open up waiver slots for other people in need. This was the first mention of a waiting list that I have been able to find relating to the DD waiver.

On December 18, 2001, two communications were sent to providers from FSSA. The first announced a 4.5% increase in reimbursement, and the other created a TCM-D (designee) position, acknowledging that there were not enough qualified QMRPs to handle the workload assigned to targeted case managers. The former, sent by the Secretary of the FSSA, noted that the original increase had indeed been set at 9%, but due to budget constraints, he had to make some sacrifices. An additional sacrifice noted in the memo was that he had to limit out-of-state travel.

These announcements resulted in another change in job description and structure. While somewhat frustrating, it was a great relief to have enough case management support available to meet the challenges ahead.

And what challenges there were! Service definitions now required 15 minute units of service, and the documentation of each one. Prevocational services were introduced, as well as necessity that the consumer must earn less than 50% of minimum wage to be served in the program. Consumers that did not meet this requirement were to be served under sheltered work. Each needed to be recorded and billed separately.

Additional clarification followed between February 2002 and April 2002. Health Care Coordination was determined to NOT be a service from which everyone could benefit. Instead, factors were identified that were to justify the need for service. Prevocational Services were clarified to require that the 50% factor was not an average, and that providers must measure productivity for every consumer, for every job, for every hour. For a busy setting, this is over 1000 separate calculations per day on top of the 15 minute documentation. More administrative support was needed to assure compliance. Service rate changes, and rounding rules were announced in late April.

The Indiana Administration was having problems of its own at this time. FSSA was depending upon the conversion to the waiver to do two things- increase community based alternatives, and to cut costs significantly. The problem was, many people did not want to move to the waiver even as they were told how much more service they could expect. The other problem was that the number of people who met the eligibility requirements and were approved for waiver were not nearly as many as anticipated.

In February of 2002, the eligibility score on the DDP was lowered from 35 to 28. Anyone who scored 28 through 34 were automatically put on the waiver, bypassing the Office of Medicaid Policy approval. In March, OMPP approval was removed entirely. Non-waiver authorization was shifted to the Bureau of Developmental Disabilities Services (BDDS) and case managers were given the authority to approve waivers on their own. The eligibility issue resolved, all that remained was to motivate individuals to choose the waiver over traditional funding.

Part III will continue the story…

The Science of Allocation

Professional 9 Responses »

Nov 032010

This is a very, very long post. For those of you who are impatient or merely intolerant, I encourage you to skip to the end (This is where I give my opinion of the two things that would potentially fix OBA). For those of you who are interested in how I came to these conclusions, I encourage you to read on and I thank you for the extra effort.

My first exposure to the scientific method (beyond the basic definitions) was in Mr. Sutton’s “Introduction to Psychology” class in High School. It was basically an overview, covering everything from cognitive development to personality theory. Before any of these concepts were discussed, however, we spent a lot of time on science in general. It was especially critical in psychology, Mr. Sutton explained, because we are dealing with people. You have to follow the rules of science very carefully. One “confounding variable,” and you do not have an objective measure. While college and grad school went into exhaustive detail on testing, statistics, and the development of theories, no single concept impacted me more than the basic components of objective science I learned in that introductory class.

We can all admit that OASIS was a flawed system. We tried to make it work, and it simply did not. The new plan, OBA, has been at the center of the debate about FSSA’s Medicaid Waiver system. Families and providers do not like it. While we all say that it is broken, very few statements have been made as to why it is so flawed. Some facts have emerged, such as its lack of a plan for outliers, the lack of consideration for extreme medical challenges, and the lack of any provision for circumstances in which a person needs 24 hour supports and must live alone. These issues, however, seem like they could be resolved with minor changes to the system. Why, then, do I (like so many others) have the nagging feeling that OBA itself is flawed?

The reason dawned on me when I was thinking about Mr. Sutton’s class: OBA does not conform to the most basic requirements of an objective measurement tool!

There are 3 things that are considered critical to any experiment, assessment or test. Thinking back to high school, I am sure everyone can recall them as well as I can:

1. The test must be VALID- It must test what it is supposed to test

2. The test must be RELIABLE- it must have reproducible results, consistently giving the same impression.

3. The test cannot be impossible to disprove- if there is no way to disprove a hypothesis (test) it is not objective.

OBA is not a test of reaction time, rats in a maze, or any other example test from school. It is an assessment that impacts lives, by determining what supports are needed by an individual and then allocating resources based on that level. The fact that such a critical assessment lacks these factors, for me, is the reason I have that nagging discomfort.

For OBA to be valid, it must actually measure consumer need. We have been told what goes into the formula (in general terms): The ICAP assessment, the “addendum questions,” and a final review by a team at the state. Is this a measure of consumer need? Without a transparent process, it is impossible to know. We can guess, though. Several months ago, amid complaints that the conditions under which the ICAP assessment was completed were inappropriate, providers and consumers were “allowed” to see the results of the ICAP and addendum questions, and send in corrections to any errors found. Almost every single ICAP had errors, as did almost half of the addendum questions. If these corrected ICAPS were used in the new OBA formula, then the validity is merely unknown. If the originals were used, OBA is demonstrably wrong in its very basis. either way, validity is compromised by the subjectivity of the assessment itself.

For OBA to be reliable, anyone should be able to look at the formula, plug in the information, and get exactly the same allocation. This allocation would need to be consistent, regardless of who administered the ICAP, who the case manager is, or when the transition to the OBA occurs. Without access to the conditions of the system, however, there is no way to assess reliability.

During the most recent DD Commission hearing, it was stated that the actual allocation amounts assigned to the OBA level were based on the cost of providing services. If these costs were recently acquired, they did not come from any provider that I have asked. In any case, reliability is compromised, because the size of the provider and the service model dramatically impact the cost of service delivery. If these costs were based on the study that was completed before the original OASIS plan, they are invalid as well. the cost studies were one of the very few pieces of information that were made available to INARF, and were shown, via actual audit reports, to be incorrect in their base assumptions.

This leads us to the final component: The ability to disprove. Without access to the actual formula, and without transparency throughout the system, there is absolutely nothing to hang your proverbial hat on.

All of this is not to say that OBA should be pulled from the table, as OASIS was in times past. Everything about OBA says, unlike OASIS, it is well thought out, and has the genuine intent of being objective and fair to all concerned. Every provider that I have encountered, and every family and consumer that I have personally known, fully supports the concept of an objective allocation methodology. OBA may yet prove to be the system that accomplishes this shared goal. There are only two things that stand in the way of making this a reality, and both are absolutely within the state’s control. Two changes would make all of the difference.

First, the entire OBA formula must be known to everyone. If it makes sense, there is no reason to hide it. If it does not, there is every reason to fear it. By FSSA being transparent in its methodology, it would cause the evaporation of much of the distrust that has been steadily growing over the last decade.

Second, there must be an honest analysis of the methodology, from many angles. Providers, advocates, and consumers must truly be at the table with the state, and all must work together to identify and eliminate the problems with the model. Just as I learned in another high school class, stake-holder input is the key to acceptance.

Where We Find Ourselves

Professional No Responses »

Oct 292010

This has been a time of change for consumers and providers in Indiana. Significant cuts in funding across all program areas have resulted in anxiety for families and a shift to “crisis mode” for providers. For the first time in my short, decade-long tenure in this field, I am seeing real risk of the elimination of services or even providers.

In the past, such funding cuts have been limited to one or two program areas, allowing for a diversified provider to subsidize programs operating on “mission” with those operating with a small margin. This type of fiscal management created an environment where even services that could not begin to pay for themselves struggled on. It was seen as a moral imperative for a provider to continue supporting those in need. Who else would?

This time, it is different. Due to the regular shifting of funds from program to program over the last 5 years, expenses have been reduced to the lowest level possible. When the latest rounds of deep cuts occurred, there was no program left to subsidize the losses. There are only a few courses available to us.

All providers operate with the goal of having financial resources left over at the end of the year. If it is a for-profit company, management has the responsibility to maintain the corporation’s value and to increase the wealth of shareholders. There is nothing wrong with this- it is basic to the American way of life. The concern lies in the fact that when revenues can no longer cover the expenses, it is necessary to eliminate programs or otherwise do what is necessary to meet the company’s obligation to the shareholders. When this happens, consumers are given notice, or are moved into environments that may not meet their needs. The uglier alternative is with companies that reduce costs by neglecting the people they serve- driven by personal greed instead of corporate responsibility. We have seen this recently, in the tragic conditions found in a decertified provider in Fort Wayne.

Community-based providers, on the other hand, will tend to continue services until they cannot function any longer. More and more management and support staff are eliminated as resources are shifted to ONLY what is necessary to do day-to-day programming. Innovation, charity care, and training beyond that which is necessary to assure client safety are put on hold. When it is not possible to continue programs at all, they either fold or are absorbed by larger providers.

Listening to the testimony at yesterday’s developmental disability commission, it was clear that there is little accurate knowledge of the plight of the provider and the ultimate consequences to the people we serve. To state that the expenses incurred in the delivery of services were considered in rate setting demonstrates the inadequacy of that research. The true cost of services are not difficult to obtain. Non-Profit provider financial statements are public record. Even a brief skim of the data will show that no one is getting wealthy and nothing is being squandered.

At another point in the testimony, it was stated that, although providers have had decreases in funding, there have been no decreases in services. A savvy parent will easily see that the game of keeping the number of service units assigned to a consumer the same, while reducing the reimbursement to the provider is an attempt to somehow shift responsibility away from the state. Ultimately, the result is the same. I very much doubt that our esteemed legislators will buy this ploy any more than they believe that taxes have not been reduced because the number of people in the state has remained the same.

This is not to say that money has not been misspent, or that there is no need to reduce the costs of providing services. The details of this will have to wait for another post. Providers and families are acutely aware of the financial state of the FSSA, and are very interested in working with the state as partners, if it is a real collaboration and not used merely to justify the original position.

For now, we find ourselves in a worrisome position. There is a lack of transparency that makes choosing a course of action difficult. Until we are able to see and understand the processes behind allocations and have some measure of stability, planning for service delivery more than a few months out will be increasingly difficult. A consistent model over many months cannot be guaranteed when the rules and funding for that model are not consistent. Like so many people we serve, we will focus on today.

Christiaan's Perspective

Looking Back (Part 6)

Looking Back (Part 5)

Looking Back (Part 4)

Looking Back (Part III)

Looking Back (Part 2)

The Science of Allocation

Where We Find Ourselves

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