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April 20, 2006
UW Outreach Building (951 N Poplar)
Casper, Wyoming
Representative Elaine Harvey, Chairman
Senator Hank Coe, Vice Chairman
Senator Mike Massie
Representative Bruce Barnard
Representative Rosie Berger
Representative John Hastert
Senator John Hines
Dave Gruver, Assistant Director, Legal Services
Don Richards, Senior Research Analyst
Please refer to Appendix
1 to review the Committee Sign-in Sheet
for a list of other individuals who attended the meeting.
Chair Harvey called
the meeting to order at 8:05 a.m. The
following sections summarize the Committee proceedings by topic. Please
refer to Appendix 2 to review the Committee meeting agenda.
Minutes from the October 21, 2005 Select Committee meeting were approved without revision.
Chair Harvey offered a brief summary of the background of the Select Committee and indicated that given the adopted legislation, which extended the Committee for one year, there is one more interim to address issues relating to services provided to people with disabilities. Specifically, issues left to accomplish include topics related to adult waiver services and receipt of reports on the new funding for preschools. She also referred to background prepared by LSO regarding comparative statistics on state services to persons with developmental disabilities. (See Appendix 3.)
WDH Comments. Dr. Brent Sherard, Director, Wyoming Department of Health (WDH); Bob Peck, CFO, WDH; and Cliff Mikesell, Administrator, Developmental Disabilities Division (DDD), WDH, collectively provided an update to the Committee regarding issues related to developmental disabilities.
Dr. Sherard indicated that WDH has no waiting list and has not had one for approximately one year. He indicated that 250 new clients have been added to all three waivers, bringing the total number of clients on the three waivers to: 1,200 adults; 750 children; and 137 persons with adult brain injury (ABI). In addition, 2,800 - 2,900 children ages birth through five are currently served in the preschool DD program.
Dr. Sherard indicated that WDH has five sets of rules, responding to a Legislative Management Audit. The rules have passed federal review by the Centers for Medicaid and Medicare Services (CMS) and the Attorney General has conducted a preliminary review of the draft rules, although the rules have not yet been formally promulgated. He noted that the rules preparation has been a long, drawn-out process. He is hopeful that there will not be substantial negative comment from the public and that the rules can be implemented quickly to provide accountability and better service for the DD community. With respect to another recommendation of the Management Audit Committee, WDH has also prepared a draft RFP for an independent review of the DOORs funding model. (See Appendix 4 for a copy of the draft RFP.)
Cliff Mikesell discussed the clinical criteria used to determine qualification for the waiver programs and for institutional placement. He indicated that an Inventory for Client and Agency Planning (ICAP) score of 70 and an IQ of 70 is an approximation of the criteria but qualification is really subject to the 1986 definition and diagnosis of mental retardation as determined by a qualified psychologist. He confirmed that the criteria for the waivers and institutional placement were the same.
Mr. Mikesell and the Committee then discussed whether elimination of the waiting list resulted in some clients not being offered the full menu of services, particularly out-of-home placement. Mr. Mikesell noted that, under the Division's emergency criteria, new clients are being offered residential placement. He added that WDH has also offered the Wyoming State Training School (WSTS) as a choice and a limited number of new clients have chosen that option.
Mr. Mikesell indicated that the decision to offer out-of-home placement comes down to funding; therefore, some clients are not being offered residential placement. He noted new clients have an average individual budget amount (IBA) of $17,000 compared to an average IBA of approximately $60,000 for existing clients, recognizing that most new clients do not have conditions as severe as the existing clients. However, if clients would have moved into a residential setting, they would have had average costs. Mr. Mikesell reminded the Committee it would take an additional $20 million to serve clients in out-of-home placement. The Committee discussed whether the client populations are being treated equally under such a system. Responding to questions, Mr. Mikesell noted that nothing speaks to out-of-home placement in the proposed rules. Mr. Mikesell indicated that, due to rising demand, he expected that a waiting list would be created, potentially as early as the fall of 2006.
Representative Berger raised the question of whether the state needs to have a discussion about having a waiting list that is reasonable. Mr. Mikesell recounted the discussion surrounding additional funding offered in the 2005-06 biennium, and his expectation that the new funding be used to address the waiting list. He also noted that there was litigation threatened over the waiting list at the time of the increased funding.
When asked about how Wyoming's waiting list (currently at zero) compares to surrounding states, Mr. Mikesell indicated that Wyoming is the only state he is aware of that does not have a waiting list. The Committee then discussed the average costs for services at the Wyoming State Training School (WSTS) and Bob Peck indicated that the average costs divide the total expenditures by the number of clients served and generally include individuals with more severe conditions.
Chair Harvey articulated that it was her personal goal to have a transparent system that assigns the level of service needed dependent upon a client's score. The Committee then discussed additional options for the provision of services, including systems in which "the money follows the person."
Management Audit Follow-up. The Committee worked
through the January 12, 2006 memo entitled "Follow-up on the 2004 Adult
Developmental Disabilities Waiver Program report" prepared by LSO's
Program Evaluation staff. (See Appendix
5.)
With respect to recommendation #1 (Alternative programs) the Committee inquired as to the status of the Real Choice Waiver. Cliff Mikesell initiated this discussion with a qualification that the waiver is still in the development stage, so not all of the details have been flushed out. Notwithstanding that caveat, Mr. Mikesell indicated that the Real Choice Waiver would have a cap of, say, $20,000 and include more self-direction and more choice. The person will be able to select his providers, which would result in a trade-off between flexibility (self-direction) and cost. Providers would still need to be certified, and WDH would require assurances that health and welfare are protected. Existing providers would be eligible to participate, but Mr. Mikesell anticipated the provider base might expand greatly. Support brokers, who would be independent, non-state employees, would direct the service provision for each client. Support brokers on the Real Choice Waiver could be case managers under the existing waivers, as envisioned by the Division at this time. According to Mr. Mikesell, a fiscal intermediary would provide for the accounting, preparation of time sheets, etc. Providers would not have to participate in the state's reimbursement system and individualized provider rates would pay what the market demanded. In sum, Mr. Mikesell indicated the money would be directed to the fiscal intermediary, and when the money is out, it is out.
Mr. Mikesell noted that a former DDD employee, Jon Fortune, was the lead on the Real Choice Waiver project, and he recently resigned. Nonetheless, he indicated the waiver is still on the Division's agenda, and WDH now has a family services group and is identifying the scope of potential services to be offered for a potential waiver.
With respect to Recommendation #2 (Promulgation of rules), Chair Harvey noted that the rules do not cover criteria for entering the WSTS, how long clients stay, and whether other rules need to be completed for the services provided to persons with developmental disabilities. Dr. Sherard noted that WDH staff struggle with the decision as to whether or not clients should be in the Training School. He views this decision similar to a medical decision to admit a person to the hospital. Given the subjectivity inherent in the decision, Dr. Sherard stated it is difficult to establish rules.
Recommendation #3 required an independent analysis of the DOORs model. Mr. Mikesell explained that the DOORs model is based upon the ICAP score of the client and uses a stepwise multiple regression to link certain characteristics and severity of disability with services to be provided. He directed the Committee's attention to the draft RFP for the independent review. (See Appendix 3.) Responding to a Committee question, Mr. Mikesell noted that the model does not taken into account regional and geographic differences, but a separate contract with Navigant, responding to Recommendation #5 may address those issues.
The Committee expressed concern over the November 30th reporting date included in the RFP and provided an alternative timeline for achieving a September 15th or September 20th date. The Committee discussed the constraints of their October 1st reporting deadline included in their authorizing statutes and noted, after discussions with LSO staff, that their report is to be delivered to Management Council, the Joint Appropriations Committee, the Joint Labor, Health, and Social Services Committee, as well as the Governor. The Committee noted the if the review resulted in policy discussions or changes, an earlier reporting date would be needed.
Rather than pursuing a RFP, Bob Peck discussed the option of soliciting a “Request for Interest” (RFI) which would allow for expression of interest or limit it to interested parties. Then, if there is a lack of response to the request for interest, WDH could work directly in a concurrent contract with Navigant.
Concluding this discussion, Senator Massie moved to recommend to WDH that it submit information and recommendations in time to be included in the Select Committee’s October 1st report. The motion was seconded and passed by voice vote.
Recommendation #4 addresses the need to establish a system to account for and fund emergency cases and forced rates. Mr. Mikesell noted that WDH has submitted two annual reports to several legislative committees, plus quarterly reports to the Joint Appropriations Committee. (See Appendix 6 for a copy of the most recent draft quarterly report.) Chair Harvey asked that the prior reports be provided to the Select Committee. Representative Barnard expressed concern about obtaining funds for emergency cases, and Senator Massie raised the possibility of establishing a one-time pot of money to account for emergency cases, similar to the emergency funds approved for the School Facilities Commission.
Recommendation #5 suggested the Division should require more justification of rates for major services. Mr. Mikesell noted that the contract study by Navigant on rate justification is already underway and will shed light on these issues. In response to Committee questions, Mr. Mikesell indicated that there are not established rates for service providers, particularly for the two major services: residential habilitation and day habilitation. He stated that WDH is looking to establish those rates and provide for recalibration. Mr. Peck indicated the rates could be adjusted by locale to take into account regional differences and perhaps the Extraordinary Care Committee (ECC) could provide for emergency inflationary cost adjustments so that there is not a six month lag to address substantial wage pressures in emergency cases.
Comments from
Regional Service Providers. Ruth
Sommers, Regional Service Providers, stressed the need for planning at the
state level and identifying what services are good and what change is
appropriate. (Her comments are
summarized in Appendix 6.) In sum, Ms.
Sommers discussed eight major points where the regional service providers
believe the Committee could focus their study:
investigation of alternative services; oversight of rules; independent
evaluation of the DOORs model; provider rate justification; impacts of
elimination of the waiting list; creation of a waiting list for residential
placement; issues related to case management; and the financial health of the
service providers. During this
discussion, the Committee asked for any information on clients desiring, but
not receiving, residential placement and whether providers are offering this
placement without waiver funding.
Responding to these questions, Chris Boston and Shawn Griffin, regional
service providers, noted that they operate community based services and,
therefore, need to be of service to the community. Shawn Griffin indicated that some individuals are receiving
out-of-home placement without payment through the waiver, but noted that it
doesn’t stretch his budget much. Chris Boston
indicated that it does stretch his budget and staff, but he believes his
organization has a moral responsibility to serve these clients. Responding to a question, Mr. Boston noted
that Social Security Disability Income (SSDI) does help with rent, but does not
help fund staff.
In conclusion, Representative Barnard inquired if Ms. Sommers was requesting an informal communication setting. Ms. Sommers responded that such a setting might bring more people to the table.
Public Comment. Brenda Oswald, Director, Governor’s Planning Council on Developmental Disabilities, came forward and indicated to the Committee that there is no state policy on not funding residential placements. She indicated that with the removal of the waiting list, the environment has changed from the "haves and the have nots" to the "cans and the cannots" with respect to residential placement. She noted that clients on the children's waiver are not denied residential services; therefore, it becomes advantageous to get on the children's waiver if out-of-home placement is desired after achieving an age to qualify for the adult waiver. She added that the current policy could push people toward selecting the Training School and there is a need to look at the impact of such a policy on the entire care system. Ms. Oswald also discussed the need to allow Medicaid Buy-In for persons with developmental disabilities. She recounted examples where there are negative incentives to earning money. In conclusion, Ms. Oswald suggested bringing in CMS staff to consider more options for the Real Choice Waiver, noting that other states have multiple waivers with different menus of services.
Richard Leslie, Wyoming Epilepsy Association and the Governor’s Planning Council on Developmental Disabilities, suggested that people need to be on the waiver and get off the waiver at some point. He noted that teaching basic skills and providing for low-income housing would help people grow.
The Committee adjourned at noon for lunch and reconvened at 1:40 pm.
Dr. Brent Sherard, Director, Wyoming Department of Health; Cliff Mikesell, Administrator, Developmental Disabilities Division; and Tiernan McIlwaine, Preschool Program Manager addressed the Committee regarding preschool services. Mr. McIlwaine discussed how regional providers are to apply for and estimate the amounts of their future budgets. He indicated that some of the information needed for the statutorily-required reports would not be included in the provider's application for funding. (See Appendix 7 for an accounting of the data required for the legislatively required reports.) Mr. McIlwaine discussed the information needed in order to respond to each of the reporting requirements. Senator Massie noted that the compensation level reporting should include information on early childhood special educators, as required by law. With respect to evidence-based practices, Senator Coe suggested that some of the practices in K-12 might be viewed as potential models.
With respect to capital construction, the last required report in the statutory list, Mr. McIlwaine indicated WDH will look at DFS square footage ratios and contract to more fully identify capital construction space issues. The Committee discussed issues surrounding the use of unused K-12 school buildings and the challenges present in this process.
Chair Harvey inquired as to how WDH intended to identify the necessary funds to pay for the statutorily-required reports since no appropriation was approved by the Legislature for these items. She urged WDH to not reduce the pass through funding going to preschool service providers. Bob Peck and Dr. Sherard both commented on the number of requests for funding within the Department's budget and WDH's effort to tighten the purse strings.
On another topic, Mr. Mikesell told the Committee that WDH previously required a ten percent private contribution be provided as a local match. He noted that this statutory requirement, addressing many public entities, was not changed with the new funding level. For clarification, Mr. Mikesell indicated that he had requested an Attorney General's opinion as to whether this statutory provision applies to private entities. Upon receipt, he offered to provide the Committee with a copy.
Kathleen Orton, Child Development Services, indicated that funding capital construction continues to be an issue, despite the passage of the increased funding levels in the 2006 Session. She asked the Committee to consider adding an amount for capital construction into the per child amount. Ms. Orton also noted that the new funding levels did not take into account the K-12 increases that were provided in the recalibration of the block grant model. Finally, she indicated that if WDH uses federal money to prepare the statutorily required reports, it will reduce funds available for services.
Donna Merrill, Stride Learning Center, addressed the Committee and indicated that her organization will not be losing any speech therapists, unlike prior years, due to the enhanced per child funding approved by the Legislature this year.
Chair Harvey indicated she would like to establish goals, a time line, and an indication of what information is needed and what information is available to assist in the work of the Committee during the interim.
Senator Massie suggested three study goals to the Committee –
1) Monitoring progress on the five recommendations from the Management Audit report including:
(i) study of alternative programs (specifically the Real Choice Waiver);
(ii) oversight of the promulgation of WDH rules;
(iii) evaluation of the DOORS model;
(iv) review of funding for emergency cases, including where the funding came from and why it was available; and
(v) justification of provider rates; and
2) Review and consideration of the appropriateness of waiting lists and the provision of out-of-home placement to more clients served by the waiver; and
3) Preschool reporting requirements as required by statute.
After significant discussion by the Committee, the Committee expressed general support for the identified goals. Senator Massie moved to add review of the State Training School, with specific attention to the rules for admission and release as well as how the services offered fit into the entire system of care for persons with developmental disabilities. His motion was seconded and adopted. The Committee also discussed reviewing issues related to case management. However, due to time constraints and priorities, this topic was not adopted by the Committee.
Chair Harvey indicated that the Committee will meet again in Lander for a two-day meeting to discuss waiting lists and out-of-home placements; the role of the State Training School; as well as an update on the action taken on the five Management Audit recommendations. The Committee will also schedule a tour of the WSTS. She directed LSO staff to poll all Committee members and attempt to establish dates in May or June for which the most members could attend.
There being no further business, Chair Harvey adjourned the meeting at 3:45 p.m.
Respectfully submitted,
Representative Harvey, Chair