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Tag Archives: DADS

Over the past few months, the Texas Sunset Commission has issued reports and recommendations about each of the agencies under the Health and Human Services umbrella. For example, here’s a write up I did about their recommendations for the state supported living centers: http://wp.me/pZf7K-9t and here’s one for the Department of Aging and Disability Services: http://wp.me/pZf7K-9p /

The Texas Sunset Commission has completed its review and recommendations for the Texas Health and Human Services Commission (HHSC). The full report can be found here: https://www.sunset.texas.gov/public/uploads/files/reports/HHSC%20and%20System%20Staff%20Report.pdf . The Sunset Commission issued 15 recommendations pertaining to HHSC, only a few of which will I discuss in detail:
• Health and Human Services agencies should be consolidated
• Medicaid can be administered better
• Participation in Medicaid by providers is being discouraged
• There is a need to improve quality of health care
• There are too many advisory committees

Consolidation:
The Health and Human Services system has expenditures of almost $35 billion annually with 54,000 employees. This is spread out across five agencies. It is the Sunset Commission’s opinion in their report that the size and scope of the five agencies creates blurred accountability, fragmentation of programs and services, “organizational misalignment,” ineffective regulatory services, and some real challenges with the current organizational structure of the enterprise. For example, the report mentions that the Department of State Health services has a focus that is too broad, the existence of the Department of Aging and Disability Services is questionable after Senate Bill 7 (managed care), and the Department of Assistive and Rehabilitative Services has too narrow of a focus and some of its programs and services are duplicated by DADS.

As a result of the above, the Sunset Commission recommends:
• All the agencies be consolidated into one.
• Organize the new entity along functional lines:
o Central/support services (i.e. administrative support)
o Medical and social services
o State institutions and facilities
o Family and protective services
o Public health services
o Regulatory services
o Office of inspector general
• Establish a policy and performance office

Medicaid can be administered better:
The Sunset Commission found the Medicaid is fragmented because it is administered by DADS, DSHS, and HHSC. This leads to a lack of communication, a lack of policies and program administration, duplication, and inefficient delivery of services. The recommendation is to consolidate all the Medicaid programs (waivers, entitlement programs, YES waiver, etc.) to HHSC, which falls in line with the consolidation recommendation above.

Participation in Medicaid by providers is being discouraged:
According to the Sunset report, only 31% of physicians are willing to accept new Medicaid clients. The report finds that it is too difficult to enroll (it may take three to twelve months to navigate the state’s system and become enrolled as a provider), there are huge administrative burdens on the part of providers, and the reimbursement rates are low. As a result, the Sunset Commission is recommending that HHSC streamline and centralize the provider enrollment process, streamline the criminal history process and require a fast (10 day) turnaround.

Health care quality:
According to the Sunset report, there are 270 different initiatives to improve the quality and outcomes of Health and Human Services programs and services! This creates a lack of focus, administrative burdens, inefficiencies, and missed opportunities. The Sunset Commission recommends that HHSC develop a comprehensive, coordinated plan to ensure consistent approaches for improving the quality of health care and require HHSC to pilot incentive-based payments by managed care organizations.

Advisory committees:
HHSC has 41 advisory committees. In 2013 this amounted to 189 meetings, 16,700 staff hours, and cost the state $800,000. Most of these committees are established by legislation and have reporting requirements, which adds to HHSC’s administrative burden. There are six managed care advisory committees, four committees dealing with children, five committees dealing with quality matters, etc. Needless to say, there is a lot of duplication with questionable effectiveness. As a disclaimer, I’ve served on two of the children’s committees.

The Sunset Commission recommends that the advisory committees be removed from statutes, allowing HHSC to establish by rule those that are necessary. It recommends combining the four children’s committees into one. It also recommends that HHSC create a master committee calendar, meetings be streamed, and that meeting materials be accessible online.

I’ve only covered five of the recommendations, the Sunset Commission made 15 for HHSC. As you can see from this, though, the recommendations are huge in scope and needed. From here, it gets mired in politics. I have a feeling this is going to be the issue for the Legislature this spring. It is worth reading these reports and contacting your legislators and letting them know if you support these recommendations or not.

The Department of Aging and Disability Services has published its Legislative Appropriations Request (LAR) for the 2016/2017 biennium. The full report can be found here: http://cfoweb.dads.state.tx.us/lar/default.asp .

The LAR is the important first step in the state’s budgeting process. This represents the agency’s priorities and wish list. The Legislature will factor some of this in when determining the agency’s budget. This is important because these dollars, while large, represent services to people with intellectual and developmental disabilities. The table below shows what was budgeted for the 2014 and 2015 biennium compared to what the agency is asking for in the 2016/2017 biennium. Keep in mind that Texas budgets according to two year cycles, so 2014/2015 represents the combined budget of both years as does 2016/2017. The column at the end shows you the change. A positive number means that the agency is asking for more, a negative number indicates they are asking for less, and a zero means essentially no change.

The breakdown of the LAR can be found here: dadslar

As requested by DADS, there are major changes to the funding of community based alternatives, primary home care, and SSLC capital repairs/renovations. DADS is requesting increases in hospice, guardianship, community attendant services, CLASS, DBMD, regulation, administration, and IT program support.

In addition to the LAR, DADS is also requesting several exceptional items. Frequently the LAR requests by strategy represents no change to services. In other words, this is the cost for the status quo. The exceptional items represents new things the agency would like to do.

The first exception item is funding to maintain the current caseload for many of the waiver programs (HCS, CLASS, DBMD, MDCP, Texas Home Living Waiver, non-Medicaid services, and PACE). This exceptional item is asking for approximately 111 million dollars over the biennium. In their justification, DADs mentions that the current biennium (FY 2014 and 2015) had the funding to expand waiver slots, particularly in HCS, but a failure to continue funding those into the next biennium (i.e. a failure to grant this exception item) will result in people losing care.

The third exception item deals with funding to reduce waiver interest lists. If funded, this exception item would add 15,145 slots for community-based services and cost approximately 724 million dollars over the biennium. It would fully fund the STAR+PLUS community-based alternatives, the deaf-blind multiple disability lists, would serve about 20% of the people on the interest lists for HCS, MDCP, TxHmL, and CLASS. For In Home and Family Support and IDD Community services, it would serve about 10% of the people on those interest lists.

The fourth exceptional item deals with promoting independence for individuals with intellectual and developmental disabilities (IDD). This represents a little over 85 million dollars to either move people from facilities or keep people from having to go there. If funded, it would move 500 individuals from large or medium-sized intermediate care facilities, 216 children aging out of foster care, 400 crisis slots for individuals for individuals at imminent risk of entering a large/intermediate care facility, 120 individuals with IDD in the state hospitals, and 25 for children transitioning from a general residence facility.

The fifth exceptional items seeks to enhance community IDD services for individuals with complex medical and/or behavioral needs. This is an exceptional item that is meant to address things that the Sunset Commission noted. DADS is requesting approximately 57 million dollars over the biennium to the fund new crisis respite and behavioral intervention programs, and increase the ICF and HCS rates to encourage treatment.

The seventh exceptional item relates to protecting vulnerable Texans. This item requests approximately 41 million dollars over the biennium to hire new guardianship supervisors, expand the Lifespan Respite Care program, increase the HCS cap on dental expenses to $2000 per individual per year, to provide assistance to small HCS facilities for required fire sprinkler systems, and would increase regulatory tools.

The either exception item deals with the state supported living centers. This one asks for approximately 112 million over the biennium to finance repairs and renovations, to finance a replacement plan for vehicles, and to reclassify some positions.

In my last post (https://jcissik.wordpress.com/2014/09/11/texas-state-supported-living-centers-mixed-signals/ ), I wrote about the Texas Sunset Advisory Commission’s recommendations for the Department of Aging and Disability Resources (DADS) with regards to the state supported living centers. While important, these are not the only recommendations that the Commission had for DADS. In this post, I’m going to cover some of the other recommendations (and you can see the full report here: https://www.sunset.texas.gov/public/uploads/files/reports/DADS%20Commission%20Decisions_0.pdf ).

The issues covered in this blog are related to the idea of eventually closing down several of the state supported living centers. All of these are issues that should be thought about and addressed if the closure of those facilities is going to work.

People with greater needs need more support
If people are going to be transitioned from the SSLCs to the community, they may require more support. The report notes that two thirds of local authorities do not have crisis intervention teams for people with intellectual and developmental disabilities (IDD), and those that do will run out of funding in 2016 unless the 1115 demonstration waiver is renewed.

The report notes that it is challenging for individuals to move from the SSLC to the community due to a lack of providers that can meet their needs. One reason for this is that reimbursement levels are so low that it creates “a disincentive to care for the medically fragile population in the community” (Sunset report, page 32).

With the above in mind, the Commission made a number of recommendations (all of which they ultimately passed):
1. Require DADS to expand crisis intervention teams to provide increased supports to people with IDD in the community.
2. Require DADS and the Health and Human Services Commission (HHSC), in rule, to add a reimbursement level that incentivizes providers to open small and specialized group homes to people with high medical needs.
3. Allow SSLCs to leverage their experience and knowledge and provide services to community clients for a fee

People in day habilitation facilities should be able to expect adequate care
This issue deals with day habilitation facilities, which provide services during weekday work hours. The Commission notes that day habilitation facilities are not licensed by anyone, so the quality of the care and services varies greatly from good to very poor. In addition, DADS does not require any safety or quality measures in contracts with day habilitation facilities.

The Commission made the following recommendations (all of which they ultimately passed):
1. Require DADS to develop contract provisions regarding basic safety and service requirements for day habilitation facilities (things like run background checks, conduct fire drills, etc.).
2. Require DFPS to track data on abuse, neglect, and exploitation in day habilitation facilities.
3. Track and report violations at day habilitation facilities.

In addition, the Commission will require DADS to create an advisory committee on the redesign and potential licensure of all day habilitation facilities.

Long-term care providers should provide safe and quality services

According to the report, DADS oversees over 10,000 providers serving over 1.3 million Texans. The report notes that DADS issues few sanctions for violations. In fact the report found that in 2013, DADS took enforcement actions on 225 out of 38,000 confirmed violations. This is influenced by several things including providers having the right to “correct” their violations without penalty, a lack of teeth in penalties, and an appeal backlog.

The Commission recommended that (all of which they passed):
1. DADS develop progressive sanctions for serious or repeated violations
2. DADS repeal the “right to correct” provision
3. Make the penalties more expensive

DADS needs to do a better job managing contracts
DADS oversees about 4300 contracts worth about 2.3 billion dollars. The Commission’s report notes that DADS has a fragmented and inefficient approach to managing contracts. For example, DADS has 11 agency divisions that oversee contracts. This disorganization leads to delays and cost overruns that could have been prevented. The Commission basically directed DADS to restructure its contract management to centralize it, standardize it, and become more intentional about monitoring contracts (all of which were ultimately passed by the Commission).

All of the above issues relate back to the idea of ultimately closing the SSLCs. If the SSLCs are closed down, or if some are closed, then the people residing there (or the people who may reside there one day) need to go somewhere to have their needs met. These places need to be able to provide the services they need, in a safe environment. All of this is going to require some pretty serious changes on DADS’ part.

The Texas Sunset Advisory Commission is looking at the Health and Human Services agencies in Texas. In their report for the Department of Aging and Disability Services (DADS), the Commission made several recommendations that have the potential to have implications in the lives of those with intellectual and developmental disabilities (IDDs). The full report can be found here: https://www.sunset.texas.gov/public/uploads/files/reports/DADS%20Commission%20Decisions_0.pdf .

One of their recommendations deals with the state supported living centers (SSLCs). With this blog I’ll discuss the background in the report, the committee’s recommendation, and its final decision and the politics associated with that.

Background:
According to the report, the SSLCs consume about 10% of DADS’ budget, account for 80% of its workforce, yet serve less than 1% of its clients. The operation of the SSLCs requires almost 14,000 employees, almost $563 million dollars, and this serves about 3650 individuals. The report notes several things:
• Texas, by operating 13 SSLCs, is out of step with the rest of the country. In 2011, Ohio and New York were both operating 10 institutions, this represented 36% and 43% of the institutions they had operated in 1960. Texas on the other hand is still operating 87% of the institutions it had in 1960.
• Texas, rather than incentivizing the shifting of resources and individuals to community settings, is incentivizing the closing of community settings.
• As of April 2014, the SSLCs were in compliance with 18-40% of the Department of Justice settlement requirements. Recall that in 2009, the DOJ entered into a settlement agreement with the State of Texas over abuse, neglect, and deaths in the SSLCs (see that agreement here: http://www.justice.gov/crt/about/spl/documents/TexasStateSchools_settle_06-26-09.pdf ).
• The number of confirmed abuse, neglect, and exploitation allegations at the SSLCs is equal to approximately 15% of the population of the SSLCs, this compares to 6-10% in group homes.
• As has been mentioned by others (see the Legislative Budget Board report here: http://www.lbb.state.tx.us/Documents/Publications/Policy_Report/Transform%20State%20Residential%20Services%20for%20Persons%20with%20Intellectual%20and%20Developmental%20Disabilities.) the cost to operate the SSLCs is unsustainable. This is due to a combination of aging infrastructure, costs of compliance with the DOJ agreement, and injuries to employees (i.e. workers compensation claims).
• The average monthly cost to support a resident of the SSLC is almost three times the cost in a residential community home.

Recommendations:
The report makes the following recommendations:
1. Close the Austin SSLC by August 31, 2017. The rationale is that this is the worst of the SSLCs in terms of abuse/neglect, employee injuries, difficulty meeting DOJ settlement, etc.
2. Establish the SSLC closure commission to determine an additional five centers to close.
3. Require those closures by August 31, 2022.
4. Direct DADS to improve the quality of life for residents in the remaining seven SSLCs.

Final Decisions:
1. Close the Austin SSLC: 105 people testified to close, 190 testified to keep open including Representative Myra Crownover, Represntative Lois Kolhorst, and Senator Robert Nichols.
2. Closure commission: 105 people testified for, 266 against including the above named legislators and Representative Susan King
3. Close five SSLCs: same results as in recommendation 2 above

As a result of the above, the committee’s decisions are:
1. Close the Austin SSLC, all proceeds go to services for people with IDD
2. Establish a SSLC restructuring commission to make recommendations to the Legislature by December 1, 2016
3. Require DADS to close any SSLCs recommended by restructuring commission by 2025
4. DADS must submit a plan to improve the quality of care in all SSLCs by December 2014

State agencies in Texas are required to go through a review process (called the Sunset Review) to determine if they are still needed and to look at the agency’s performance. In general this occurs every 12 years. Currently, the Health and Human Services agencies in Texas are undergoing this process. This post deals with the Sunset Review’s report on the Department of Aging and Disability Services (DADS). This is not meant to be a comprehensive summary of the report, in fact you can access the report below:
https://www.sunset.texas.gov/public/uploads/files/reports/DADS%20Staff%20Report.pdf

DADS provides most of the long-term care and support for individuals with intellectual and developmental disabilities.

This post is going to deal with the following recommendations of the report:
• The state supported living centers
• Transitioning from state supported living centers to the community
• Ensuring adequate care in the community
• Enforcing violations
• Contract management

State Supported Living Centers (SSLCs):
SSLC residents account for less than 1% of the agency’s clients but represent 10% of DADS’ budget and 80% of its workforce. As of September 2013 there were 3649 residents and 13,906 staff being funded by almost $563 million. The report reviewed some of the issues with the SSLCs:
• No SSLC is in compliance with the Department of Justice settlement agreements from 2009. The SSLC range from being in compliance with 18% of the requirements (Richmond) to 40% (Lubbock).
• The number of confirmed allegations of abuse, neglect, and exploitation at SSLCs is shocking and in 2013 represented 15% of the population of the SSLCs.
• In 2002, the SSLC population was a little over 5,000 residents with a funding around $300 million. In 2013 that population was 3649 with appropriations coming close to $700 million.
• All of the SSLCS, except one, require infrastructure repairs that will cost more than the SSLCs are valued at. Only Denton is valued at more than the cost of its infrastructure repairs.
• Almost 10% of SSLC employees are injured annually.
• The average monthly cost for serving a resident of an SSLC is approximately $9500 than a community option.

As a result of the above, the Sunset Review report recommends the following:
• Close Austin SSLC by August 31, 2017
• Establish a closure commission to evaluate the SSLCs and determine five more to close
• Close five more SSLCs by August 31, 2022

Transitioning from SSLCs to the community:
The report notes that many individuals in SSLCs have complex behavioral, mental health, and medical issues. With that in mind, certain supports need to be in place to successfully move them from a SSLC to the community. As a result, the report recommends:
• Requiring DADS to establish crisis intervention teams statewide
• Require DADS (and HHSC) to reimburse services appropriately so that providers will open group homes to people with high medical needs
• Allow SSLCs to provide services to community clients

Ensuring adequate care in day habitat facilities:
This recommendation affects almost 35,000 individuals in community settings. The report finds that DADS doesn’t really monitor day habitat facilities and that the agency’s rules vary across program so there are no quality or safety standards. As a result, the report recommends:
• DADS develop basic safety and service requirements for community based programs. The report suggests things like running fire drills, running background checks on employees, following the client’s plan, etc.
• Require that abuse, neglect, and exploitation be tracked.
• Track data on services offered and deficiencies.

Enforce violations:
In fiscal year 2013, DADS took enforcement actions on only 225 out of 38,000 confirmed violations of state regulations, federal regulations, and Medicaid contracts. Among other issues, DADS has inadequate penalties to deter violations, has difficulty collecting them, and has a serious backlog in cases. The report recommends:
• Develop progressive sanctions for serious or repeated violations
• Repeal the “right to correct” provisions for providers and require DADS to define the criteria for their appropriate use.
• Authorize higher financial penalties to incentivize compliance.

Contract management:
DADS’s approach to managing contracts is fragmented which results in a lack of information, accountability, and inefficiency. This also creates cost over runs and project delays. The report recommends:
• Require DADS to consolidate all contract management
• Have the centralized contract management review and approve contract planning during the early stages of the procurement process
• Develop policies for the risk-based monitoring of contracts

Taken together, the findings and recommendations show you just how bad things are for individuals with IDD in Texas. The SSLCs are bad, the community settings are better but are unregulated and have little incentive to prevent/address deficiencies, and the agency has challenges with oversight and protecting/serving individuals with IDD. This report comes out while we’re transitioning people with IDD to managed care and it is chilling to think how much worse things can get under that system if they are already this bad.

The report provides some opportunities, however. First, realize that just because it is in the report does not mean that the state is going to act on it. This means contacting your legislator and dragging them, kicking and screaming, towards supporting its implementation. Second, the advocacy groups should be aligning some of their legislative foci around these recommendations. This way the Legislature hears the same thing from everyone. Third, SB7 (managed care) is only legislation, it is only a law. This means it can be changed via legislation. Maybe it’s time to get the Legislature to revisit it, slow it down even more, or even kill it in the upcoming session.

Yesterday I participated in the Children’s Policy Council’s briefing for the Texas legislature.  The Children’s Policy Council (CPC) was established by the 2001 Legislature to help provide recommendations to the state about integrating services to children with special needs to provide the services that are needed in a more effective, cost-effective, and integrated way.   It’s membership is primarily parents of children with special needs, which allows it to provide a unique perspective to the state.  Every even-numbered year, the CPC produces a report with recommendations for the Legislature.  The 2012 report can be found here: http://www.hhsc.state.tx.us/si/C-LTC/2012-CPC-Leg-Report.pdf .

 

The CPC conducted a briefing based upon the recommendations found in the report to the Legislature and state agency employees in the state capital yesterday.   I’m happy to report that staffers from about 25 representatives and senators attended as well as staffers from the Department of Assistive and Rehabilitative Services, the Department of Aging and Disability Services, and the Health and Human Services Commission.

 

I discussed the need to fully fund Early Childhood Intervention (ECI).  I have covered a lot of the issues elsewhere (see: http://wp.me/pZf7K-7F for the most recent summary), but none of the CPC assumed knowledge on the part of the people attending the briefing.  I began by discussing what ECI is and what it does.  I explained that there is a narrow window (birth to age three) when services can be provided to children that might be less expensive and easier due to the fact that children are developing rapidly at this age.  Failing to address delays at this age doesn’t make them go away, it makes them someone else’s problem (the school districts and society’s) which becomes more difficult and more expensive as the child ages.

 

After that I covered the history.  Namely that the funding for ECI has been cut for several years.  In fiscal year 2010 it was 197 million dollars.  In FY2012 it was 163 million dollars.  In FY2014, DARS is asking for 145 million with an additional 40 million in exceptional items.  The result of this has had an impact on how many children receive services as well as who those children are.  As I have written about elsewhere, I explained the consequences of the Legislature’s short-sightedness with ECI and explained why it needs to be fully funded.

 

With one exception, all of the other presenters at this briefing were parents.  This was powerful as it provided a human face to the services and programs that the CPC is recommending.  One of the parents, Cheryl Fries, began her presentation by talking about her “D Day,” the day her family received the diagnosis of their child’s disability.  She told those attending the briefing that each parent of a special needs child has their D Day burned into their memory and that none of us asked to be part of this club, but we’re all members nonetheless.  I thought that was a powerful statement and I’m going to borrow that in the future.

 

The one exception was Dr. Carl Tapia, who is a pediatrician specializing in children with special needs.  He discussed the CPC’s recommendations for reforming acute Medicaid services.  The CPC has been involved in making recommendations to the state about redesigning both long term services and supports as well as acute Medicaid services.

 

I found the briefing to be a positive experience.  We had a good turnout and I felt that they were attentive and asked questions.  Now how things play out during the upcoming session is anyone’s guess…

Below is a copy of my written testimony for Texas’ Department of Aging and Disability Services’ Legislative Appropriations Request hearing, which is scheduled for September 11, 2012. The full document of the LAR is located here: http://cfoweb.dads.state.tx.us/lar/default.asp and this represents the first round of hearings for what will be the department’s 2014 and 2015 budgets:

I want to thank the Legislative Budget Board and the Legislature for the opportunity to comment on the Legislative Appropriations Request (LAR) for the Department of Aging and Disability Services (DADS). I am the parent of a five year old with Down’s Syndrome who will one day be an adult with Down’s Syndrome, so I am very interested in the services offered by the state of Texas. In addition to being a parent, I also serve as an appointed parent representative on the Children’s Policy Council, the Task Force for Children with Special Needs, and the Early Childhood Intervention Committee. In this letter, I’d like to ask the LBB and the Legislature to consider several items that were in DADS’ LAR as well as several items that were not.

With regards to items that were in the LAR:
• This LAR reflects a shift over to managed care. It is also reflecting the fact that whether we like it or not, costs increase and this must be accounted for via appropriations. If it is not, then the only way to balance things out is to reduce services. DADS is attempting to do this via two of their special items; maintaining caseloads and cost trends. These items represent approximately $101 million in FY14. If these special items are not funded then DADS will have to reduce services to Texans.
• If the state of Texas is committed to maintaining the State Supported Living Center (SSLC) system, then funds must be made available to keep them modern and well-staffed so that they are able to provide the best services possible to the residents. With that in mind, then the special item dealing with this (approximately $112 million in FY14) must be funded.
• It is in the best interests of Texas, and the individuals affected, to have people move from residential facilities to the community. In the community there are fewer risks of abuse, better opportunities for work, and an ability for people to thrive. Two of the special items (promoting independence and community expansion) that total approximately $151 million in FY14 deal with this and should be funded.

There were several items that were not in the LAR that I’d like to ask the LBB and the Legislature to consider:
• Health Management Associates issued a report in October of 2010 recommending establishing a pilot program using a non-capitated enhanced care management model for individuals with intellectual and developmental disabilities. The idea being that this can result in cost savings, open up additional waiver slots, and eventually (hopefully) lead Texas down the road to these services becoming entitlements like in other states. DADS should include this in the LAR (and in associated budget presentations) to get this pilot program funded for the biennium and lay the groundwork for possible future expansion of the program.
• Prior to the 2011 Legislative session, the Legislative Budget Board issued their report calling for a number of changes to the state supported living centers. Their recommendations were to include a rider in the general appropriates bill directing DADS to close at least one SSLC; to include a rider requiring DADS to submit a closure plan; to include a rider to authorize DADS to reclassify one FTE position to direct the closure process; and to amend the Health and Safety Code to establish a realignment/closure commission (for SSLCs). These recommendations did not go anywhere in 2011. DADS and the LBB need to provide leadership on this matter and resubmit these recommendations to the Legislature in order to give DADS the flexibility to modernize its services in this area. The fact of the matter is that the SSLCs are not sustainable and the most fundamental issue with them is the fact that there simply is not enough money to hire and retain the caliber of front-line staff, keep the facilities and services modern, and provide the residents the opportunity to thrive.

• It is important that future planning with regards to health care, Medicaid, and the improvement of services for individuals with special needs must be integrated. Often, these planning efforts are disconnected or driven by whim and this ensures that they will fail. Committees can draft reports, they can develop plans, but if they are not integrated and supported by the state agency strategic plan and the Legislative Appropriation Request then they are doomed to failure.

Thank you again for the opportunity to comment on this important matter. Thank you for your service in these difficult times.

The Legislative Appropriations Request (LAR) for the Department of Aging and Disability Services (DADS) in Texas has been published.  The full document can be found here: http://cfoweb.dads.state.tx.us/lar/default.asp.  In Texas, the way the budget process works is that it is done by biennium (this is because the Legislature meets every two years).  So, during the summer of the even-numbered years the various agencies submit their LAR.  This is what they want their budgets to be given instructions and limitations provided by the state’s leadership.  This goes to a hearing before representatives of the Governor’s office, the Legislature, and the Legislative Budget Board (LBB).  The LBB then makes recommendations based upon this to the Legislature, who prepares and votes for the budget which the Governor then signs (or vetoes).  The actual budget that the agency receives for the biennium may or may not reflect what they submit via their LAR.

 

The current biennium is FY2012 (the current year, which ends August 31) and FY2013.  The LAR that has been submitted will cover FY2014 and FY2015.  So in this blog I’ll compare FY2012 to FY2014.  I’m only going to focus this post on DADS’ goal of providing long-term services and supports.  I won’t post anything about their regulation/outreach and indirect administration goals.  The long-term services and support goal has several objectives and supporting strategies.  These include intake/access, waivers, entitlements, community services, nursing facility payments, promoting independence, ICF’s, and state supported living centers.

 

The current fiscal year (2012) has approximately $6.4 billion budgeted for these.  DADS is requesting $6.15 billion for fiscal year 2014 (the first year of this LAR), a 3.5% decrease.  Much of this is due to the roll out of STAR+PLUS and services being absorbed by STAR+PLUS.  This decrease is primarily coming from the following areas:

  • Primary home care: this is the providing of non-skilled personal care services.  This is seeing a major reduction (FY12 to FY14) due to STAR+PLUS, which will eventually see this strategy be eliminated.
  • Day activity and health services:  This refers to adult day care services and is another being impacted (and eventually eliminated) by STAR+PLUS.
  • Community based alternatives: This is a service designed to help keep people out of facilities, it’s another that is impacted by STAR+PLUS and will eventually be eliminated.
  • ID community services: The intellectual disability services are seeing a reduction of approximately 14% comparing FY2012 to FY2014.  This is due to the administrative expenses being transferred elsewhere and to some of the individuals receiving services being transferred to the Texas Home Living Waiver (see below).
  • Promoting independence by providing community-based services: This service is designed to help get people out of residential facilities and back into the community.  It is seeing a reduction due to STAR+PLUS.
  • State supported living centers: The state supported living centers are seeing a strange funding pattern.  From FY2012 to FY2013, they are losing 1.3% of their funding.  From FY2013 to FY2014, they will see a 0.6% increase in funding, partially restoring some of what was lost. 

 

The following areas are actually seeing an increase in this LAR:

  • Community attendant services: This increase seems to be balancing out the reduction in primary home care.
  • Home and community-based services (HCS Waiver): Compared to 2012 HCS is seeing a large increase in funding (roughly 4%).  But this is fairly flat compared to FY2013’s funding.
  • Texas Home Living Waiver: Compared to 2012 this is seeing a large increase in funding (roughly 41%), but this is flat compared to FY2013’s funding.  This increase over FY2013 represents instructions from the current appropriation’s act to provide services to more individuals via this waiver.
  • ICF’s: Intermediate care facilities for an individual with an intellectual disability are seeing an approximately 1.3% increase in funding from FY2012 to FY2014. 

 

Now, DADS also has eight exceptional items which will impact many of the areas highlighted above.  The amounts shown reflect all funding sources for FY2014 only:

  • Maintain caseloads: approximately $11.4 million.  The instructions that DADS received on this LAR were essentially no new growth in their baseline request.  If that is done, by 2014 they will not be able to maintain 2013’s caseload levels – which means reducing the number of people serviced.  This exceptional item is meant to keep that from happening.
  • Cost trends: approximately $90 million.  DADS was instructed to show cost increases, rate increases, etc. as exceptional items.  DADS points out that they have no ability to control these cost increases and failing to fund this will reduce services.
  • Promoting independence: approximately $20 million.  This exceptional item is meant to get a number of individuals out of residential centers and to provide crisis services to individuals in immediate risk of institutionalization.
  • Community expansion: approximately $131 million.  This item would increase community services for individuals on interest lists.  For example, it would serve 20% of the eligible individuals on HCS and CLASS interest lists.
  • Protecting vulnerable Texans: approximately $12 million.  This would add staff and help upgrade IT systems in areas like guardianship, ombudsmen, adult protective services, etc.
  • Improving support for SSLC residents: approximately $112 million.  These are infrastructure improvements to the state supported living centers.  Things like furniture, computers, IT upgrades, vehicles, repairs/renovations, etc.
  • Streamlining service systems: approximately $9 million.  This is primarily an information technology initiative.
  • PACE expansion: $1 million.  This would add additional PACE slots and fund new sites.

 

All of these exceptional items total about $385 million for FY2014, of that $258 million would be from Federal funds or other funds, only $127 million from the state.  In FY2015, these exceptional items would expand to over a billion dollars.  This is primarily from the following:

  • Cost trends: expands to $195 million
  • Promoting independence: expands to $60 million
  • Community expansion: expands to $765 million
  • PACE expansion: expands to almost $11 million

 

Of this billion dollars, $337 million would be from the state with the rest from Federal and other funds.

 

How will this LAR potentially impact Texans with disabilities?  First, it demonstrates that Medicaid recipients are going to be rolled into managed care, which has pro’s and con’s.  Second, it’s renewing the commitment to the state supported living centers and the ICF’s.  Third, there is never going to be enough money to fund the number of waiver slots needed, combined with the increase in costs.  Finally, in my opinion the exceptional items should be called “Things We Need  To Do Just To Hang On,” if they are viewed as superfluous by the state’s decision makers then this will end up hurting the elderly and disabled in Texas.

The Department of Aging and Disability Services (DADS)in Texas  is asking for feedback about its Legislative Appropriations Request (LAR) for the 2014-2015 biennium.  This will be another difficult budget time between state financial concerns and the Federal government budget concerns.  Below is the feedback that I provided to DADS.  Some of this is taken from the earlier comments I had on SB7.

 Thank you for the opportunity to provide input on DADS’ LAR for fiscal years 2014-2015. I am a parent of an almost five-year old with Down Syndrome. I have also been appointed as a parent member to the Children’s Policy Council (established by HB 1478 of the 77th Legislature), the Task Force for Children with Special Needs (established by SB 1824 of the 81st Legislature), and the Early Childhood Intervention Advisory Committee. Not only am I living this as a parent, but I’m also involved in attempting to change things to provide better services to children like my son.

I think there are a number of areas where DADS can provide leadership via this LAR:
• HMA’s Pilot to Serve Persons with Intellectual and Developmental Disabilities
• LBB’s 2011 report on “Transform State Residential Services for Persons with Intellectual and Developmental Disabilities”
• Integration of planning
• Senate Bill Seven
• Stakeholder Input

HMA Pilot:
Health Management Associates issued a report in October of 2010 recommending establishing a pilot program using a non-capitated enhanced care management model for individuals with intellectual and developmental disabilities. The idea being that this can result in cost savings, open up additional waiver slots, and eventually (hopefully) lead Texas down the road to these services becoming entitlements like in other states. DADS should include this in the LAR (and in associated budget presentations) to get this pilot program funded for the biennium and lay the groundwork for possible future expansion of the program.

LBB 2011 Report:
Prior to the 2011 Legislative session, the Legislative Budget Board issued their report calling for a number of changes to the state supported living centers. Their recommendations were:
1. Include a rider in the general appropriates bill directing DADS to close at least one SSLC
2. Include a rider requiring DADS to submit a closure plan
3. Include a rider to authorize DADS to reclassify one FTE position to direct the closure process
4. Amend the Health and Safety Code to establish a realignment/closure commission (for SSLCs)

These recommendations did not go anywhere in 2011. If DADS were to provide leadership, include this in its LAR, and champion these recommendations this would go a long way towards giving DADS the flexibility to modernize its services in this area.

Integration of Planning:
It is important that future planning with regards to health care, Medicaid, and the improvement of services for individuals with special needs must be integrated. Often, these planning efforts are disconnected or driven by whim and this ensures that they will fail. Committees can draft reports, they can develop plans, but if they are not integrated and supported by the state agency strategic plan and the Legislative Appropriation Request then they are doomed to failure.

Senate Bill Seven:
Senate Bill 7, passed by the 2011 Legislature in special session, serves as an example of increasing government waste and inefficiency while attempting to reduce it. The bill seeks to reduce Medicaid and health care issues impacting children with disabilities to a handful of outcome measures in order to simplify an enormously complex problem. In so doing, it requires no less than 14 different reports, studies, and assessments and sets up new government entities that will require ongoing funding diverted from areas that could be providing direct services to children with disabilities.

Each of the reports that SB7 requires (some are for the Legislature, some for the Governor, most are for both) will require staff time to collect data, analyze data, compile reports, brief agency officials, and prepare agency officials for Legislative testimony. Each of these reports will lead to situations where state agencies will seek new streams of information from health care providers in order to satisfy the needs of the reports for data. The combination of all of these efforts will mean that more resources are being devoted to collecting, analyzing, and reporting data rather than providing services to children with special needs. While the Legislature’s desire for knowledge is admirable, I question how influential this data will ultimately be in the decision-making process.

SB7 also requires a number of studies by HHSC and DADS. These are described in sections 1.02 (patient centered medical homes, external quality reviews, payment incentives), 1.09 (physicians incentives), 1.12 (performance incentives based upon outcome and process measures), 3.01 (outcome measures of quality and efficiency), 6.05 (preventable events for hospitals/long-term care facilities), 6.07 (data by facility), and 6.08 (study on incentives and recognition of health care quality). While the intent behind these studies is admirable, they will result in health care providers spending more time and resources on these and less on direct services and it is unclear that these studies will uncover any information that is not already known.

DADS should educate the Legislature, via the LAR, about the hidden costs and ripple effects that this kind of micromanaging has.

Stakeholder Input:
I appreciate DADS soliciting stakeholder input on the LAR. Often, stakeholder input is solicited towards the end of planning instead of at the beginning. I would like to encourage DADS to continue soliciting stakeholder input at the beginning and during the planning process, rather than just with the final product.

It’s been awhile since I’ve blogged about anything relating to advocacy. The 82nd Texas Legislature ended without a budget and the special session came during a busy summer personally and professionally. That said, I spent today in a meeting of the Children’s Policy Council. During this meeting, representatives from the Texas Health and Human Services agencies reported to the council about the budget and how this will impact the future.

In a word the situation is bleak and it’s going to get worse. There is an expectation that after this biennium (fiscal years 2011/2012 and 2012/2013) the situation in Texas will get even worse than it is currently. Not factored into what I’m going to cover is the fact that the U.S. lost its AAA rating and there is a debt reduction deal.

Let’s talk about the macro (i.e. Federal) perspective first. Many HHS programs in Texas depend upon Federal matching funds. Nobody thinks that the Federal government can reduce the deficit without touch Medicaid, which has an impact on many HHS programs. The rise in interest rates may have an impact as well.

Looking at the impact on the various state agencies:

Health and Human Services Commission:
In all funds, they are looking at a 17% reduction. Some of this is from the loss of the Federal stimulus funds. It assumes reductions in provider rates (i.e. Medicaid providers) in the form of hospital rate reductions, DME and lab service rate reductions. It also has “cost containment” (you’ll see this phrase a lot with the various agencies) initiatives.

An important thing to note about the budget, Medicaid is not fully funded. It’s only funded for the first six months on 2012/2013. The intent is for the Legislature to pass a supplemental bill to fund Medicaid. However, this usually doesn’t happen until March which means that HHSC and DADS will probably have a cash flow issue. Their expectation is that they will be unable to pay providers or meet their own payrolls in 2012/2013.

HHSC programs are not funded to take account of caseload growth, cost growth, or utilization growth.

Department of Aging and Disability Services:
DADS is (all funds) being reduced by almost 30%. No organization can withstand this and remain effective. As I have blogged about elsewhere, this includes many direct service programs to the elderly and the disabled. It impacts institutional programs and well as programs designed to keep people out of institutions.

In addition, DADS has a Legislatively-mandated cost containment initiative with all the Medicaid waivers. This initiative says that people will only be funded up to the 90th percentile of services in select waiver programs. In other words, let’s say that you receive 100 hours of a given service from one of the Medicaid waivers. If this service is greater than the 90th percentile of everyone else receiving that service, the service that you receive will be reduced accordingly. Now, there is an appeals process but this has to be initiated by the provider, not the consumer. This goes into effect December 1st, 2011 and DADS will have a stakeholder meeting tentatively scheduled for August 22nd. The Children’s Policy Council plans a letter to DADS expressing concerns over the details of implementing this, but with this being Legislatively driven DADS has few options.

Texas Education Agency:
TEA has had several waves of reductions in force over the last year plus resulting in an almost 30% reduction in the number of employees. In addition, TEA is being reorganized so that special education is being decentralized and spread across the agency. This will have an impact on knowledge, quality, and accountability.

The TEA rep expressed some concerns about HB1335 which gives classroom teachers the ability to order a review of IEPs. In theory this sounds good, but what it means is that there could be a situation where a school district and parents are happy with the IEP, but the general classroom teacher sets the whole thing on its ear. It’s also possible that this review could be conducted without the presence of the parents.

Department of Assistive and Rehabilitative Services:
DARS spent their time talking about the changes to ECI after the 14% reduction in funding. I’ve blogged on this elsewhere, but there will be a narrowing of eligibility, fewer ECI contractors, increased cost share from families, and measurable outcomes.

As you can see, direct service programs are hit hard by the “new normal” (i.e. do more with less). As I said earlier, the future is probably going to be a lot more bleak after 2013.