OASIS » Christiaan's Perspective

Looking Back (Part 7)

Jul 052011

After a long process, a new allocation system, called OBA, was presented as the replacement for the OASIS project. As so much discussion was had with families and providers, the finished product was eagerly anticipated. OBA was originally based on a simple mechanism- The level of support that one consumer requires should be similar to another consumer with similar characteristics. As some services can be shared, the number of housemates is also a factor. With so much stakeholder input and such a simple mechanism, what could go wrong?

In October of 2010, the first indications of concerns began to surface. A quarterly bulletin was released, describing the OBA system as a combination of living situation, medical and behavioral review, and the ICAP (The same assessment that was such a concern during the OASIS allocation period). The ICAP, when released to providers after OASIS, proved to be so inaccurate that providers were asked to validate every question for every consumer. This process did not actually correct the ICAP, but just indicated whether the provider agreed or disagreed with the accuracy of each answer.

To be fair, all of this was (and is) happening in a very difficult economy. Like everywhere else, sacrifices must be made and the collective belts of providers must be tightened. Reimbursement rates were cut for many waiver-funded services. Providers understood this, and created cost-saving proposals, which were submitted by INARF (our trade association) to FSSA. Because of the friction that existed between providers and the state at this point, these proposals were looked upon with suspicion, and ultimately went nowhere.

When the January, 2011 OBA amounts were released to families and providers, the concern increased dramatically. Allocations, while not as random-seeming as the OASIS allocations had been, were still unpredictable. Provider teams, using the descriptions provided by DDRS, had estimated the “ALGO” scores in advance, based on their knowledge of the consumer. The January scores did not correspond to the estimates made by the people who served the consumers every day. Individuals that received minimal support and did not want an increased provider presence were allocated amounts that would never be used. Individuals that required, and had been getting higher levels of service found themselves without needed resources. There was a generalized fear that history was repeating itself.

As tension rose in the provider community, attitudes changed. Providers rejected every plan that the BDDS put forth, and BDDS, in turn, rejected provider suggestions. Transparency evaporated. Committees were never reconvened. Trust vanished. In short, all of us had an opportunity to work together for a solution, and we squandered it. State officials are convinced that providers are greedy, Providers are convinced that the state is unreasonable, and families are convinced that their needs don’t matter.

We stand today in the middle of the most challenging time in the history of our field. As a provider, I am seeing the lowest reimbursement in Waiver history, while the cost of service provision is at its highest. The State must reduce spending to be responsible, but is faced with every single entity stating that they cannot survive on reduced spending. There has been such an outcry from all corners that the Federal government is scrutinizing every decision made in Indiana by the state government and service providers. Families are just fed up, and are waiting for something new to come along.

And so concludes “Looking Back,” with a clear indication that we must begin looking forward. If we (collectively) decide that the history ends now, we have all failed. It is time to take a breath and count to 10. We all know that the current system is not sustainable.

Perhaps I am being naive, but I can envision the next chapter as a fundamental change in how we address the problem. With a few acknowledgements and concessions, we can create a model that actually does as it is intended. It will require a few things, though:

The State

The state must acknowledge that any system that keeps itself hidden will lead to distrust. It must be open to input from stakeholders, and be prepared to publicly address concerns and revise things that are clearly not working correctly. It must stop pretending that the solution to meeting the needs of someone who needs constant, vigilant supervision is to authorize most of a full day and then ask the provider to find a roommate.

Providers

Providers must stop insisting that any reduction, to any service, to any consumer, is a crisis. We have a tendency to appeal any reduction, even if it is to a service that the consumer never uses. We need to stop working under the assumption that the State is deliberately trying to make things difficult, and admit that, just like us, they are trying to make 5 pounds of resources fill a 10 pound bag.

Families

Families need to be more active in the process, instead of waiting for Providers and the State to work things out. The ARC of Indiana makes a very good point when it says that families need to use what they need instead of demanding everything and then letting the provider and the state fight it out.

All in all, we will be judged on the decisions we make now. This time can be remembered as when we reversed course, opened up micro-institutions, accepted the lowest common denominator as the service we would render, and ultimately made decisions based on fear and finance. Or, this could be remembered as the time when we grew up, laid all of the cards on the table, and developed an efficient and transparent method of delivering high quality, efficient services to individuals who need them.

The solution cannot be developed unilaterally. Only candid discussion will result in an effective solution. Each entity, individually has a third of the equation, and must be willing to share it with complete honesty.

From the State: How much money is available for the provision of services to people with disabilities.

From Providers: How much does service provision cost? What would each unit of service cost on its own, without using it to subsidize other services or being subsidized itself?

From families: What do you really need? Ignore the fear of losing what you don’t use or trying to anticipate the potential for future needs. What support, at a minimum, do you need right now for health and safety?

Within these three facts lies a sustainable and effective plan for service delivery. Let’s do this.

Looking Back (Part 6)

Professional No Responses »

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)

Professional No Responses »

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)

Professional No Responses »

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…

Mapping a New Course- the Arc of Indiana

Professional No Responses »

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!

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.

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.

Idea

Professional No Responses »

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…

Now What?

Professional No Responses »

Mar 172009

With Friday’s announcement from FSSA, freezing OASIS allocations until further notice, there has been a lot of cheering and celebrating from consumers and providers alike. I must admit that I reacted in much the same way. We all must realize, however, that this is the beginning of the process, not the result.

I am still fully convinced that, even without an official requirement, uniform rates are a necessary component of any well-run system. I have no doubt that, whatever changes are made to OASIS, it will include this methodology. The dollar amounts must also be something that is predictable to the state, so that they will know how to budget and how to project expenditures into the future. This predictive system must be based on what is anticipated, however, rather than what is automatically allocated as a maximum amount that could be expended. The latest model is a good example of why this is necessary, as it dramatically increased allocations to people that have no intention of using them. These over-allocations could have been used as a pool for those who have needs beyond what their current allocation will support.

Any new system must also be flexible enough to allow consumers to maintain the supports and services that have been long-term parts of their plan. By submitting their current schedule of services, information on how often they deviate from that schedule, and if there are any preferences or needs that the consumer feels are critical, we can have a better picture of the consumer/family expectations PRIOR to the allocation decision.

Finally, an allocation system must be transparent to avoid the problems and criticisms surrounding the original OASIS model. If there have been errors in assumptions made, providers are more likely to be able to determine where those errors lie, in that they can compare specific individuals to specific assumptions over time.

Beyond that, I really have very little more in the way of ideas. Without knowing what was originally attempted, the necessary parameters, and the assumptions made, any suggestion would come from a position of ignorance. I am sure however, that any provider, consumer, guardian, or advocate would agree with me that we are willing to discuss options and provide feedback to whatever comes next.

Older Entries

Christiaan's Perspective

Looking Back (Part 7)

Looking Back (Part 6)

Looking Back (Part 5)

Looking Back (Part 4)

Looking Back (Part III)

Mapping a New Course- the Arc of Indiana

The Science of Allocation

The Sheltered Workshop

Idea

Now What?

Categories

Archives

Links

Meta