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Tag Archives: SSLCs

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.

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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

The filing deadline for legislation in the 83rd Texas Legislature is coming up fast. There are two new bills that have been filed that have implications for the intellectual and developmental disability community. The first is a relatively short bill by state Senator Rodriguez, the second is a very long bill by state Representative Raymond.

Senator Rodriguez has previously filed two important bills on the state supported living centers. One, SB 729, would establish a realignment commission for the centers. Another, SB 1045, would allow for the system to be evaluated. Both bills are important bills. On the 7th, Senator Rodriguez filed SB 1361, which is a bill of rights for people receiving Medicaid long-term services and supports. This bill is important especially in regard to the changes to the system that are in progress via legislation. The bill begins with the statement that: “It is the policy of this state that, to the extent provided by state or federal law or policy, each recipient of Medicaid long-term services and supports under a state benefits program has the right…” It goes on the list things like living independently, control the recipient’s own life, receive the supports necessary for competitive employment, be a participant in designing/implementing/monitoring the outcomes and effectiveness of delivery systems, receive services that are based on their individualized needs, receive services that are monitored for quality, to receive services that are effectively coordinated, and that allow individuals to retain their existing providers. Some of this bill is philosophy, which is fine, but some of it would provide some safeguards especially in light of the possible shift over to managed care.

Representative Raymond, who is the chair of the House’s Human Services committee, filed HB 2721. Essentially this is the House’s version of Senate Bill 7, which would shift the acute and long-term services and supports for the waiver recipients (HCS, CLASS, TxHmL, and DBMD waivers) over to managed care. Like SB7, the bill has great intentions. The goals include provide services to more individuals in a cost-effective manner, improve access to services, promote person-centered planning, integrate service coordination, promote high-quality care, etc. Like SB7, this is a huge bill and will have a major impact on people with IDD and their families.

Let me begin with the things that I like about this bill. First, there are extensive stakeholder input requirements in the bill:
• Like SB7, it would establish a system redesign advisory committee that would include stakeholders. This committee has an important role all through the process, basically up until 2024.
• Like SB7, the state will roll out pilot programs to test the concept. Stakeholder input is required on the pilot programs.
• HHSC is required to receive and evaluate stakeholder input when transitioning each of the waivers over to managed care.
• Stakeholder input is required for developing a quality-based payment plan to providers.

Second, the bill emphasizes the need to ensure there is continuity of care when transitioning from the old waiver programs to the new managed care approach. Third, when discussing acute services, the bill states that HHSC will use STAR+PLUS “or the most appropriate integrated capitated managed care program delivery model.” So there is some wiggle room on using STAR+PLUS. Fourth, the bill mentions implementing basic attendant and habilitation services. Fifth, and this is needed, the bill will establish specialized training for family members/caregivers/providers of people with IDD that are at risk of institutionalization and behavioral intervention teams to help prevent institutionalization. Finally, the bill provides for a wellness screening program to help prevent diseases.

So there are some things to like about HB 2721. There are also concerns. It’s a huge bill and a sweeping change and the Devil is always in the details. People with IDD have complex, varied needs. No two are the same, it’s more complicated than breaking a leg. It’s also something that cannot be fixed or treated, it requires a life-long, continuous approach to services. It’s unclear how effective any managed care organization is going to be. The current system is incredibly complex to navigate, add transition and having to learn a new system on top of that and family members will be confused and overwhelmed.

Some version of this bill or SB 7 will probably pass and become the future. With that in mind, input is critical at every step of the process. That starts now by contacting your legislators. That continues by having strong advocates on the system redesign committee and by providing input in every way possible about concerns and experiences. It must be kept in mind that the people drafting the legislation and eventually the rules and procedures don’t have first-hand experience with this system and don’t understand how complex the services are for individuals with IDD. As a result it’s very important to educate them about this.

Regarding Senator Rodriguez’s bills, they will have to pass through the Senate Health and Human Services committee. Below is the link to that committee, listing every member of the committee. Contact them about your thoughts on these bills:
http://www.capitol.state.tx.us/Committees/MembershipCmte.aspx?LegSess=83R&CmteCode=C610

Regarding HB 2721, this will pass through the House Human Services committee. The link is below, again contact each member about your thoughts:

http://www.capitol.state.tx.us/Committees/MembershipCmte.aspx?LegSess=83R&CmteCode=C310