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.

 Posted by Christiaan at 5:56 pm  Tagged with: , , , , , , , , , , , , , , ,

Mapping a New Course- the Arc of Indiana

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Nov 102010
 

I had the pleasure of attending the 2010 Arc Conference yesterday.  Not only was it great to reconnect with friends and to hear another John Dickerson blockbuster presentation, the magnitude of the ideas outlined by the Big Minds Group left me absolutely energized.  If you have not already done so, I strongly recommend paying a visit to the Arc’s Pathways Page to get a rundown.

This is not the first that I have heard of the “Pathways to Empowerment” initiative.  I have always been a fan, but I must admit that I was wondering what the ultimate call to action would be, and how it would fit into our current struggles as an industry.    I am happy to report that yesterday, my enthusiasm increased dramatically.

Our dual role, as a service provider and as an Arc Chapter, has been remarkably easy most of the time.  Indiana is very fortunate that in times long before me, the industry and the advocates decided to work as partners.  While the Pathways initiative may be frightening in some circles, I believe that most providers, families, and advocates will ultimately see the wisdom in moving in this direction.  There will be debate on many of the ideas to come, but the underlying facts will be hard to dispute:

1.  We have spent an ungodly amount of time and money arguing, complaining, tweaking, negotiating, and complying with the current system.  Perhaps the “system” itself needs some scrutiny.

2.  The Medicaid Waiver has been a blessing and a curse.

3.  The current system is the result of a lack of partnership between the state, providers, and consumers.  A fusion of competing agendas is not a partnership.  We need something new.

4.  Some consumers have more services authorized than they have the ability to use.  Others do not have nearly enough.

5.  The state needs to reduce what it spends, and providers cannot reduce their expenses any more without jeopardizing health and safety.

If these things are true, then the solution cannot come from yet another iteration of the current model.  It may get us by until the next time, but all of these issues will resurface over time.  The Pathways approach seeks to start a much needed conversation.  While providers can still be considered the core source for services, they can no longer be considered the core source for a meaningful life.  This must come from a blend of family, friends, work, community service, and service providers-the places that all of us turn to for meaning.

People have been throwing around the phrase “natural support” for a long time.  I think that many people, including providers and the state, interpret this as meaning “free service.”  There is no such thing as free service- someone always pays, even if it is the provider itself.  As John pointed out, shifting things out of a centralized rationing of limited resources and into a collaborative effort between many involved parties is where we need to be looking.  Finding that place should be the basis of our discussions.

In order to make such an effort work, however, there must be a few things in place.  First, there must be an adequate and immediately accessible crisis intervention system funded by the state, so that as new things are tried there is an underlying safety net.  Next, providers must be allowed the flexibility to provide services based on individual consumer need- Residential Habilitation may look entirely different from one individual to the next.  Finally, we must fully embrace the work-first model- we must start early, identify the talents of each individual, and assume from the start that each individual will have a place in the workforce- as an employee, a trainee, or a volunteer.

Above all, we must get these conversations going.  We must take a hard look at what is broken, and decide what can be repaired and what is simply defective.  Service providers are in no danger of disappearing.  We provide specialized services that are not easily replaced.  As the cost of providing these services is not likely to decrease, we must depend upon innovation and collaboration to fill in the gaps and work toward making the waiting list a thing of the past.  I look forward to the discussions to come!

 Posted by Christiaan at 9:45 pm  Tagged with: , , , , , , , , , , , , ,

Person-Centered Puzzle

 Professional  1 Response »
May 072009
 

Please bear with me through this scenario:

I have always been a fan of beautiful ceramics- Especially the green McCoy pieces one can find in antique stores. Part of me has always felt that I could create such objects, if only given the opportunity to practice. I could take a class, study the masters, and eventually perhaps even turn out a vase or two. As I have no innate talent in ceramics, however, it would always be a hobby at best. In fact- for me to dedicate my life to ceramics would be irresponsible, as without the aptitude it becomes merely a form of self-indulgence.

But this is precisely what we ask people with disabilities to do when the Person-Centered Planning process goes awry.

The Person-Centered movement is one of the most important changes to ever occur in our field. In retrospect, it seems impossible to believe that there was a time when service delivery was NOT based on the unique needs and desires of the individual. What else could a provider possibly base services upon?

Another key component of good service delivery is a community-based focus. Every person has the right to be a member of the community, living out his or her life with the same rights, responsibilities, and expectations as anyone else. The people we serve need assistance in some areas, but that assistance should support their life in the community, not draw attention to the ways that they may be different.

The Person-Centered Plan has slipped recently into what can more accurately be called a Dream-Centered Plan. The hopes and dreams of the individual are being identified and noted, just as they should be. The team discusses how to best support the individual to reach for these dreams occurs, just as it should. On many occasions, unfortunately, the planning process ends at this point, with the plan focused exclusively on whatever he or she has identified as a desire.

This practice is NOT person-centered or integrative. By not considering the services a person needs to increase self-sufficiency, develop skills, and secure their place in society, we are perpetuating their need for paid support. Just as it would be irresponsible for me to spend all of my time on pottery, even if I REALLY like it, it is irresponsible to create an annual service plan consisting of one or two goals such as “Go on Vacation,” “Meet the President,” or “Be in a movie.”

These dreams are important, and should be validated and accepted. Providers should assist in doing what can be done to fulfill them. Dreams are part of what make us unique, and should be celebrated as such. They should not be our only mission in life.

I can understand how this came to pass. For many years, individual desires took a back seat to what could be fit into an existing program. Realizing the failures in this practice, it was only natural for the pendulum to swing past center as corrections were made.

It is now time to look at the process again. Person-centered must refer to the whole person, and not just a few components. Desires AND needs must be identified. Outcomes are only meaningful if they mean something to the individual. Reworking and reformulating the same thing, even if it is a dream, can’t hold much meaning over time.

I don’t think that even McCoy created pottery to the exclusion of all else.

 Posted by Christiaan at 3:32 am  Tagged with: , , , , , , ,

The Sheltered Workshop

 Professional  3 Responses »
Apr 032009
 

I have been hesitant to write this post, due to the intense controversy that the topic tends to generate. Ironically, this controversy is not so heated in conversations with consumers, but tends to be a philosophical discussion between different organizations. Personally, I tend to be on the fence, as I see very good arguments on both sides. Besides, similar to the “meaningful day” issue, it is pretty presumptuous for me or anyone else without a disability to talk about what is in the best interest of another.

The argument against the workshop, obviously, is that it is not an inclusive atmosphere- that being in this environment does not allow integration into the community. The change in waiver service definitions that prohibit any specific job skills training makes the use of pre-vocational services as a stepping stone to community employment more challenging than ever.

The argument for sheltered work is mostly found in conversations with consumers who attend this service, and have done so for a long time. In multiple interviews, I hear the same thing: “I like it here.” “This is my job, why should I get another?” “My friends are here.”

So, the people directly able to choose (consumers and families) choose sheltered work as an option, even as providers and advocates work to find the most inclusive environment possible.

I had a long conversation with Mike Callahan (of customized employment fame) at the annual INARF conference, and I asked him what he thought of sheltered work. He said the problem may stem from the fact that well-meaning people will ask a transitioning person with a disability if they want to work. For people without a disability, this is never a discussion.
I don’t have any answers for the Sheltered Workshop question. I have seen some very good things happen in workshops, and very happy people working. I have seen skills developed, friendships made, and wages earned. I have seen people with and without disabilities working side by side to make quality products. I have also seen people with disabilities working in community settings who are happy, making friends, and earning a wage in an integrated setting. All people deserve to spend the day in a situation that is meaningful to them, regardless of where or what it is. I have a few thoughts, though, on what would be needed to work toward a compromise between the two opposing viewpoints.

First, addressing Mr. Callahan’s concern, transition programs must assure that all options are open, starting with post-secondary or community employment. As Indiana VRS already supports this program, these options should be the first ones on the list. Facility-based options can be discussed at parental or consumer request. As the Medicaid Waiver service definitions state, facility based employment programs should not approached as a final destination, but as needed training with the goal of community-based employment. It becomes part of a continuum that is regularly reviewed for each consumer.

In order for this to work, however, the service definition for Pre-Vocational Services would need to allow for job-specific training. That way, in following the community-based employment model, skills are taught that are in line with the consumer’s desired outcomes and specific needs. Training tracks could be utilized to prepare an individual for the job in which they plan to apply.

Finally, for any community-based training alternative, funding must be made available to support it. An individual who has multiple or significant disabilities may need job coaching for a very long time, if not indefinitely. In order to be supported individually, this will probably be costly. The bottom line, however, is that strong beliefs remain strong beliefs only, unless there are resources to put them into effect.

There are solutions to be found, certainly. These solutions will only be found, though, by open and frank discussion that does not devolve into anger. Service models change over time, but abrupt change or unsupported change are disastrous to all.

 Posted by Christiaan at 3:18 am  Tagged with: , , , , , , ,

Idea

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Mar 272009
 

A regular source of friction is the process of quality assurance and state surveys. In the past, there was a lot of frustration over the lack of clear guidelines for surveyors on how to interpret the letter of the compliance statement. In a lot of cases, the lack of a piece of paper would significantly damage the results of a high quality program. The new BQIS, and the new survey process, is significantly improved. Providers are reporting that it is about quality and person-centeredness. I think everyone can get behind that process!

Although providers have copies of the survey instrument, and share the underlying philosophy of the survey, there is still the potential for interpretations of the process to lead to confusion or frustration. The way areound this is actually very simple: Have the QA director (or another agency representative) attend the same training at the same time as the surveyors. That way, all can benefit from the exchange of ideas and questions that arise. All parties want the same thing- an emphasis on best practices and quality services. When all are engaged in the process, and all understand the expectations, more resources can go toward innovation instead of revision.

I also believe that consumers absolutely must be a part of this process as well. Self-advocates and families generally know their rights, but not the full extent of what makes a good partner in a provider and what they should EXPECT, above and beyond personal rights assurances. With all of these pieces in place, a person with a disability knows what a provider should be doing, a provider knows what they should be doing, and the surveyor becomes a best-practice consultant.

Just a thought…

 Posted by Christiaan at 7:26 pm  Tagged with: , , , , , , ,

Change Function

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Feb 262009
 

I was reading a journal the other day, and was struck by a quote defining the term “Change Function.” This was defined by the moment when a perceived crisis is worse than the perceived pain of adoption. How well this relates to organizations that serve people with disabilities! As we are generally caught between the need to innovate and the need for stability, “best practice” tends to fall somewhere in the middle. Our consumers, as well as our employees, tend to be most comfortable with the maintenance of the status quo. Any change is best done slowly, and with great care that it does not undermine service quality by failing to identify an unintended consequence.

Technology is available that can greatly increase the efficiency of provider operations. Electronic documentation, timekeeping, and new models of service are available that are much better and faster for gathering information and using it effectively. Compliance with State and Federal regulations can be assured by building them into the systems themselves. More time can be spent in direct support when less time is devoted to burdensome documentation. Still, in light of this, most providers stay with paper based systems, focus on programming areas that have not changed in decades, and devote very little time to trying new approaches to service. When innovation is critical, providers tend to look for existing models that are newer than the model they currently embrace.

I think the reason for this is two-fold. First, providers have an enormous amount of rules, regulations, laws, and cultural beliefs that must be observed. If an existing system has made it through a few audits, and everyone seems OK with it, there is an enormous perceived risk in changing anything about it. When change is forced (by new regulations or beliefs) there is a tendency to change just the area in question, forcing new information into old models. The other reason to avoid updating systems, especially electronic systems, is that in recent years there have been massive shifts in billing and documentation requirements handed down by the state. There is a lot of risk in purchasing systems at high dollars that may be obsolete within months.

The one unavoidable fact of being a provider in Indiana is that the cost of providing services and the amount of needed service will continue to rise, while the available revenue to pay for it will shrink. We are indeed entering a “Change Function” period. The system must change and grow, and people must be served. It is critical that the State and providers work together to find a solution. Providers want to do the best job they can in meeting the needs of consumers, and the government is responsible for assuring prudent expenditures of taxpayer dollars. I do not see these priorities as being in conflict. The system we are transitioning into right now is clearly broken, and many providers are in danger of closing their doors. Some are responding by demanding a freeze of all change, in favor of the status quo. Others are attempting to negotiate, with little success. Most are just keeping their heads down. Here are the facts as I see them:

  1. The world is changing, and the way providers do business must also change.
  2. Standardized rates are absolutely necessary for a level playing field, and they must cover the expense of providing that service.
  3. Providers really do more about providing services in their field than state officials. This is not meant to be an insult, but a statement of fact. An agency with a 50 year record of quality service will know how to do it better than any administration. Compare and contrast State-run institutions and community-based providers for numerous examples (of both programmatic quality and cost effectiveness).
  4. Any system that adds complexity adds cost. Simplify and excel.
  5. Providers will be able to identify ways to reduce costs if a system is in place long term. Innovation cannot happen is an environment that is always in “beta.”
  6. Providers will need time and capital to purchase and develop systems that are more efficient. This will save money in the long run, and will allow a shift in expenses from overhead to wages for DSP’s.
  7. Providers and the government must work together as partners to make things right. There should be discussions with known quality agencies, not just the largest ones. A positive response from a provider serving 10 counties does not balance a negative from 10 providers serving a single county. Urban and rural providers must both be polled.
  8. State policy and provider expectations should not be reduced to the lowest common denominator. It is a regular event for a rule for all providers to change in response to the bad behavior of a single provider. This stifles innovation. Providers who break the rules should be called on the carpet instead of being buried in an overall environment change. To swipe a phrase from my CEO, “That is eliminating islands of excellence in favor of a sea of mediocrity.”
  9. There are already established service fees that are uniform in Indiana. These are set legislatively and are on the books. This is a good starting place.
  10. Non-profit agency financials are public record. It is a very easy thing to verify that taxpayer dollars are being spent wisely and appropriately. By encouraging for-profit companies to be transparent with state dollars as well, there can be a true grasp of the costs of service provision, and funding mechanisms can be tailored to support them.
 Posted by Christiaan at 2:35 pm  Tagged with: , , , , , ,

Introductions

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Feb 042009
 

For this initial post, the most appropriate topic to address is to answer the obvious, “Why are you doing this?”

While there are excellent resources for families and advocates through the ARC of Indiana and through Family Voices, providers generally have difficulty interacting with them. I believe that one reason for this is that the relationship between the provider and the consumer is very personal, and discussions about complicated issues tend to “muddy the waters” and make it about business. Another reason is that providers tend to respond to questions as “The Expert,” and wind up lecturing instead of discussing.

It is my sincere wish that this blog will break down those barriers and begin a discussion that includes everyone: People with disabilities, providers, advocates, and those that are a combination of all of the above. We are in the middle of one of the most complex transitions I have ever encountered, and while I am designing programmatic changes, documentation issues, billing, consumer choice, and compliance with regulations, I know that the definition of a meaningful day cannot come from anywhere other than purposeful dialogue with all stakeholders. I also know that this definition will be different for all who define it.

 Posted by Christiaan at 3:40 pm  Tagged with: , , , , , ,
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