5 Myths About Brokerages Services

Information can be hard to come by sometimes in the IDD service system. We’ve heard these five myths thrown around like facts over the years, and we’re here to set the record straight.

1. MYTH: Brokerage services are only for people who don’t need much help.

FACT: Brokerages serve people with all levels of support needs, from those who are more independent to people who need frequent assistance. Support Services are meant to keep people out of Medicaid-funded residential placements and in their own or their family homes for as long as possible by supplementing the help they already receive with paid supports. This combination of family/community help and paid help can help even medically-fragile folks stay out of facility-based care, and at home with their loved ones.

2. MYTH: I have to come to Brokerage services knowing exactly what I want, or they won’t be able to help me.

FACT: We can figure it out together. Brokerages are all about helping you create goals for the life you want to live, both long and short term. Sometimes it only takes a meeting or two to talk over the possibilities and decide on a plan. Other times it’s a longer process. Your Personal Agent will be there with you, whatever you need, with more formal Person-Centered Planning, or just the time to talk it over.

3. MYTH: Each Brokerage has its own rules.

FACT: While each Brokerage is a separate, independent agency, we all follow the same state rules and guidelines. The Oregon Administrative Rules can be found online here. The rules specific to Support Services only can be found here, though we are beholden to many of the other rule areas, such as Case Management. In addition to the administrative rules, the state Office of Developmental Disabilities Services gives us guidance on specific topics in the form of worker guides, manuals, and documents such as the In-Home Expenditure Guidelines. That said, we are independent agencies, with our own business models and operational policies and procedures. While we devote a lot of time to aligning our understanding of the rules, there are times that we will come to different conclusions. We hope you’ll be patient in bringing issues to our attention so that we can find a solution.

4. MYTH: I don’t have a lot of money, why do I need services from a broker?

FACT: We aren’t fiscal brokers, we’re disability services brokers. This means that in addition to basic case management, our Personal Agents help connect people to direct service providers that fit their needs. People who qualify for these services are all eligible for Medicaid, which means that not having a ton of money in savings is part of the enrollment criteria. The funding you get through Support Services is a social benefit, through state and federal funding sources. This means that your service funds are tax-payer dollars, and while it’s important that we are good stewards of these funds, it won’t cost you anything to access them.

5. MYTH: Brokerages are all full, if you choose one you’ll be stuck waiting for services.

FACT: Most Brokerages currently have capacity to serve new customers, and all of them work with local Community Developmental Disability Programs (CDDPs, often your county) to take new enrollments as you request them. We serve adults (18 and over) with a documented intellectual or developmental disability. If you aren’t yet eligible for IDD services, you need to call your local CDDP and ask for an intake worker. The CDDP staff will help you through the eligibility process from there. Click here for the county phone directory. Once you’ve been found eligible for IDD services, all you need to do is let your intake specialist or current county case manager know that you’d like to work with a Support Services Brokerage. Visit the My Brokerage, My Choice website to find out more about the Brokerage(s) serving your area. Please feel free to contact your chosen Brokerage to let them know that you’ve selected them; this helps us ensure a smooth referral process.

So, now you are in the know. Have you heard other rumors or myths? Tell us in the comments!

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Why Vision Matters

We have talked a lot about the series of policy changes back in late 2013 that resulted in the statewide Community First Choice K Plan, in consolidating services and payment into the eXPRS Plan of Care, and the rise of the Adult Needs Assessment as a primary point of departure for service planning and funding. Today, we believe that more change is necessary if Oregon is to regain a functional, sustainable structure for IDD services.

In our last post, we talked about the series of changes that reshaped the landscape for intellectual and developmental disability (IDD) services in Oregon. From the summer of 2013 until the close of 2015, we were taking on new processes, new forms, new rules, and new roles as fast as we could implement them. (And quite often, faster than we could implement them.) Now, as we take a breath, it feels wrong to be talking about system change again. But we are talking about it, and we have to keep talking about it, because where we have arrived isn’t where we get to stay. Our services are too costly, and they aren’t netting the kind of outcomes that we’d like to see for people in services. And therein lies the problem–how will we know success when we see it? To get to the right end, you have to go about things the right way.

source: freeimages.com

Start with a vision.  Unfortunately, just because you put a lot of energy and effort into a project doesn’t guarantee its success. We started the 2013 change process with the goal of funding our services through the Community First Choice Option (K Plan), instead of through the collection of Medicaid Waivers through which services were previously authorized. At the outset, state leadership held the belief that this change in funding authority would be a back-end change, imperceptible to people using the services. It didn’t turn out that way. Making a federal funding authority our North Star didn’t lead us very far. This perceived lack of direction was part of what compelled OSSA to come up with our Vision for the Future of Disability Services in Oregon. It’s not enough to know how we’re going to pay for the services, we need to start with why we want to have the services in the first place. What is our vision for Oregonians with IDD? How should people be treated? What place should they hold in our communities? We need to start with a destination in mind, and then figure out how to get there.

Think long-term. It’s hard for public policy to plan for the long-term. Lawmakers come and go, appointed officials change office, public opinion supports a project one day, and has forgotten it the next. This capricious nature is why stakeholders must come together and do the long-term planning and visioning with state leadership, in an effort to safeguard funding and services for future Oregonians with IDD and their families. Many of the changes enacted with the K Plan in 2013 were reactionary. We were reacting to budget holes and to federal compliance issues. Though budgetary concerns and federal compliance are both important considerations, budgets are in a state of flux, as is federal law. Responding to their whims without balancing the long-term needs of a system will not get us the results we want.

source: freeimages.com

Plan for a Whole Life, not a Service Life. When evaluating a social service, it’s easy to focus on what you can get–how many hours, how much money, what’s the upper limit? But focusing on the benefit itself won’t get a person the outcomes they desire. You have to start with an idea of the life you want–who do you want to be, what do you want to do, what’s the upper limit of your happiness? We call this approach seeking a Whole Life instead of a Service Life, and it is key to making the most out of the services available. As a community, we have to refocus on the people using these services, and the lives they want to live, connected to their communities, building relationships, and benefiting from paid and unpaid supports. When we start with a goal, we often find that we can balance the imperative to be good stewards of public funds with the necessary funding and supports to live a full life.

This isn’t a detailed plan, but it is a place to start. There will be debates and arguments, differences in opinion about where to spend and where to save. We don’t have to agree on everything. But, in the end, what matters is we are all pulling in the same direction–toward rich and fulfilling lives for all Oregonians.

Nothing Endures But Change

We have talked a lot about the series of policy changes back in late 2013 that resulted in the statewide Community First Choice K Plan, in consolidating services and payment into the eXPRS Plan of Care, and the rise of the Adult Needs Assessment as a primary point of departure for service planning and funding. The entire system still struggles to find equilibrium in the wake of such wholesale change. Equity in service allocations, rates of pay, and time spent on face-to-face services vs. paperwork has been disrupted due to choices made during the implementation of these policies. Today, we believe that more change is necessary if Oregon is to regain a functional, sustainable structure for IDD services.

Spending  When Support Services were founded back in the early 2000s, the eligibility requirements for IDD services were intentionally broad to serve as many people as possible. The hard caps on service allocations, averaging around $14,000 annually by 2012, kept service spending well in hand despite increasing enrollment. Hard caps such as this were eliminated under the K Plan, and we have seen a corresponding rise in cost-per-case within Support Services. Another reason for this rise is Oregon’s choice of assessment tool, which currently determines service allocations. The Adult Needs Assessment (ANA) is an Oregon invention, adapted from the SNAP assessment used for years to determine Adult Foster Care rates. The ANA had to be adapted quickly, and there was not time for the Office of Developmental Disability Services to ensure that the tool was a valid measure of needs, nor that it was reliable from one person to another. The resource allocation mechanism was likewise completed without adequate time to test and ensure that funding was allocated at an appropriate level. The result of the rush to implement the ANA is a tool that allocates substantially more funds than are being used, on average. It is also more medical and deficits-focused than most stakeholders would like. The ANA and uncapped service structure have combined for a precipitous increase in spending by Support Services customers–a 42% increase from April 2014 to April 2015, according to the Department’s report to the Joint Interim Subcommittee on Human Services on September 28, 2015. These spending trends are not sustainable, and a core feature of any high-quality service system for people with IDD is that they are dependable and assured from year to year.

Case management  K Plan policy created a sea-change for Personal Agents, who were essentially forced to relearn their jobs while continuing to perform them. Anyone who has had a Personal Agent since before 2013 has probably felt the crunch–less face time, slower response time, more paperwork. New reporting requirements, mandated forms, and the eXPRS database have all added layers of additional responsibility to the Personal Agent position, moving them further and further away from the people they would like to serve. Strong case management is critical to a healthy, functioning IDD system–case managers serve as the pivot point for all services, a single focus of coordination to ensure that we adhere to state and federal rules, and keep the individual’s direction and wishes primary. A change in the job description for case managers, and in the structure of case management, is necessary to refocus worker time and workforce strength.

Pay rates  Service hours have become abundant for many people in the IDD service system. However, the rate of pay attached to those hours has decreased, or failed to keep pace with rising inflation. The result of this is that individuals are simply not able to find providers for all of the service hours for which they are currently eligible. Agency providers of IDD services have hundreds of open positions across the state that remain unfilled. As the economy improves and the reimbursement rate for these services remains low, skilled, experienced providers leave the system for jobs in unrelated fields. For a more detailed discussion of this phenomenon, please check out The Cost of Compassion, a short film created by the Oregon Rehabilitation Association.

Change is coming, and we need to be prepared. In our next post, we will discuss the methods and approach we will need to employ during the coming period of policy change. We have to learn from our recent history, improve on our own performance, and learn from our mistakes if we hope not to repeat them.

Vision, January 2016: A Second Look at the Future of IDD Services in Oregon

Nearly one year ago, the Oregon Support Services Association shared our February 2015 Vision for the Future of Disability Services in Oregon. It was meant to be a comprehensive look at what we want for our service system, with ideas about how we might get there. While the ultimate vision hasn’t changed substantially, the ideas for how we get there have been refined to fit a January 2016 understanding of the world. Click here to view the OSSA Vision For the Future of Disability Services in Oregon, January 2016.

As OSSA President Larry Deal and I reviewed our vision one year in, we were both struck by how much the IDD field has learned over the past 12 months. We have necessarily been on a crash-course education in Medicaid policy, Oregon law, and the

It’s January 2016! IDD services in Oregon deserve a second look.

realities of working in the field. Oregon’s IDD system has been asking itself what is possible, what it values, and at what cost. A centerpiece of our original Vision was the suggestion that

Oregon seek two distinct K Plan options–one for Self-Directed services, and one for Agency-Directed services. Oregon’s current K State Plan is approved under Agency-Directed authority, which does not allow for the level of individual direction and control that we would seek to return. Subsequent work locally and with federal CMS has taught us that there can be only one K State Plan. However, that single plan can be written for a more complex authority that blends Agency-Directed structures with Self-Directed options. We hope that Oregon will move forward with this in the coming months as the K Plan renewal enters planning stage.

Each section has been updated with a paragraph at the bottom detailing major developments relevant to the topic. The highlights will give you a good idea of what our 2015 work has accomplished. However, we have also made comprehensive updates to every page throughout the document–if you can, please read it through.

Highlights of this January 2016 update:

• Pg. 7 Case Management Funding is new. Funding mechanism (currently, billable encounters) has increasingly dictated structure in this area (case management time is only spent on billable activities), and we need to find ways to decouple the two.
• Pg. 8 Eligibility is under scrutiny in Oregon, which has a long history of casting the doors open wide for those who need support services; we support a broad front door.
• Pg. 9 Choice Advising is given its own page, due to the rise in problems stemming from our current lack of direction in this area.
• Pgs. 11-15 describe our vision of the IDD service structure; Brokerages provide case management to adults living in their own or family homes, CDDPs provider case management to adults and children living in licensed/certified home settings, and both Brokerages and CDDPs are able to serve children in their own or family homes. There is a lot to say about how to get to this! Take a look at the details of this section.
• Pg. 16 Plan Development has changed a lot in one year, with the introduction and full roll out of the Oregon ISP document for every individual in service.
• Pg. 17 Assessment is an area in which a lot of work has been done, and even more is left to do.
• Pg. 19 Community Provider Capacity hasn’t changed a lot in the vision, but there are a lot of large structural forces at work (federal laws, collective bargaining, etc.) driving this part of the system. 2016 is a make-or-break year for this area of the system.
• Pg. 22 Data Systems have not seen the improvement that we would have hoped. We will continue to advocate for a functional, supportive statewide data system.

Our Vision for the Future is meant to be a living document, changing as conditions change and our understanding expands. We have committed to updating this every six months, especially during the rapid pace of change that seems poised to continue in Oregon’s IDD service system. Contribute your unique perspective in the comments below. Tell us what we got wrong, and what we got right. It is up to all of us to decide what comes next for Oregon.

This Week, Oregon Brokerage Association Celebrates Five Years

This weekend, the Oregon Support Services Association celebrates its 5 year anniversary!

We formed the association in 2010 just as Oregon brokerages were about to celebrate a decade of services to the Intellectual and Developmental Disability (I/DD) community. The past five years have been filled with successes, challenges, and more twists and turns than anyone could have predicted. As many of you know, today’s terrain is significantly different.

I’d like to take a moment to acknowledge the work of OSSA’s Executive Director, Katie Rose. Katie has been on the job for just about a year now and having her as a full-time leader has made a huge impact for brokerage operations and within the I/DD community at large. She has successfully represented the work of brokerages statewide through legislative efforts, legislative testimonies, partnership, training development, and advocacy. Thanks for all you do, Katie Rose.  Additionally, I would like to acknowledge the membership of the association – the brokerage directors – for their passion, their patience, and their drive. You do beautiful work and you are very much appreciated by the communities you serve.

The coming year, no doubt, will bring with it both new successes and challenges for Oregon and the community at large. OSSA looks forward to continued and deepening engagement with state leadership, community partners, providers, legislators, and, most importantly, with the individuals and families receiving services.

As we celebrate this milestone in our history, we hope you and yours are gearing up to celebrate a healthy and happy holiday season.

Our best to you and yours,

Larry Deal
OSSA President

A Diversity of Services Requires A Diversity of Providers

Community-based services are different.  In 2001, Oregon made a deep investment in community supports when it began to develop Support Services Brokerages.  This style of service, which seeks to serve people where and how they wish to live, is very different from the institutional settings of the past.  People make different choices when you let them, they express different needs than you might have anticipated–they surprise you.  Oregon found that community-based services demanded a wider diversity of providers.  People inviting workers into their homes expected different things from those providers: willingness to take direction directly from the individual as to how to do the job, and an understanding and respect for self-determination.  Brokerage customers made use of established provider agencies for some tasks, direct employees for others; and over the years, Independent Contractors, or professionals in the field who go into business for themselves, have also sprung up around in-home services and customer needs.

Independent Contractors often offer a professional level of skills and experience, as well as ancillary expertise such as sign language, to provide the targeted training needed to build a more independent life.  For many people, an experienced, capable, autonomous, self-employed trainer has meant the difference between continuing to rely on others and acquiring the skills to live more independently.  Over the years, Independent Contractors have been essential to providing this kind of high-level skills training to Brokerage customers.

In 2014, the Independent Contractor stakeholder work-group mandated by the SEIU/DHS collective bargaining agreement issued a report concluding that changes to the system had likely made legitimate classification of independent contractors next to impossible.  The group’s work included consultations with The Oregon Employment Department.  Systemic changes due to the K state plan, overlay of union representation, implementation of the eXPRS payment system, and new rate structures have all resulted in incremental shifts, accumulating to a significant transformation of the business of Independent Contractors within the field.  This shift has jeopardized their correct classification as Independent Contractors by moving them closer and closer to the appearance of employees.

Brokerages believe and have always believed that Independent Contractors fill a particular need among brokerage customers.  Diversity of providers has been a hallmark of the brokerage system since its inception.  The elimination of Independent Contractors as a distinct class of providers with a distinct set of skills to offer people with IDD will be a significant loss to the people being served by Oregon.  When high-caliber skills training and the people who provide it are no longer supported by appropriate compensation, it starts to disappear as an option for the people who need it.  Community-based IDD services require people who can offer strength-based supports–people who can work with a person to understand a goal, create achievable steps, and get there.  OSSA supports a true diversity of provider options to meet the diversity of individual needs.

PSW-ICs deserve our support.  This group of people who have established businesses around the unique needs of Oregon’s IDD community, people who have built these skills and relationships, deserve a solution that allows them to continue to flourish and contribute their professional talents to serve the unique needs of Oregonians.

Back to the Future

Let’s get one thing straight up front: this isn’t new.  Not at all.  In fact, this has been around for years.  In Oregon, we started to dream this dream fifteen years ago and more.  Support Services Brokerages started here.  Take a moment to read this treatise/article/manifesto/guide by Ellen Cummings, a national consultant on Self-determination.  What jumps out at you?  Do you see Oregon’s past reflected in these descriptions?  Do you see Oregon’s future?  Ellen begins by speaking to archaic systems that have yet to see change in the field of intellectual and developmental disabilities services:

“There are many in current unchanged systems, however, who very much want to get away from desks and paper in order to spend a maximum amount of their time doing something different have the time and support necessary to help people with disabilities build lives, but are unable to get out from under the administrative/monitoring functions within the traditional system. Creativity and spirit become stifled in many situations and once again people who have disabilities remain in their perpetual state of waiting–waiting for change, waiting for friends, waiting for a place of their own, waiting for life. The years lost will never be regained.”

 

We have talked a lot about systems change here over the past two years.  A new biennium is upon us, and now is a time for reflection, self-assessment, and redirection.  Oregon has made a lot of moves to be more compliant with Medicaid rules and regulations, expand services, and bring in more federal funding for those services.  A lot of good things have come from these changes.  Children with IDD have greatly expanded access to services.  Programs are safeguarded for years to come by closer adherence to federal rules.  So: how are we doing?  Where are we at as a system, as agencies, as Personal Agents, as people receiving services?

The structure in which Personal Agents work and individuals with disabilities are supported must respond to the following imperatives:

• that people with disabilities are living the lives they want to lead, are happy and healthy, and have solid relationships
• that people with disabilities have opportunities for generating income
• that people with disabilities are participating citizens of their communities
• that approval of individual budgets be in the hands of individuals and their Personal Agents, as long as the bottom line is not exceeded
• that Personal Agents and their Coaches (mentor/supervisors) are getting the kind of information, support, and training they need
• that communication is clear and consistent
• that there is a buffer between this unit and the difficult, complex systems issues which will still be covered by traditional case management
• that the Personal Agents operate within a line item budget which is controlled by them for the performance of their work
• that authority over expenditure of dollars allotted to this unit lies in the hands of those who work in the unit
• that the dollars allotted be used more wisely and that they help build a positive future for the individual–an investment in one’s future
• that evaluation of performance includes input of those receiving support

As the dust begins to clear, what will we miss as we look around us?  What parts of ourselves, of our shared history, have been neglected in this sweeping change?  The point of asking this question isn’t to lament the good old days.  Looking at our past with rose-colored glasses gets Oregon nowhere.  Instead, we look to our beginnings to instruct us on how best to rebuild a system stronger, and more compassionate, than we could have imagined before.

Because this isn’t new, and we should not pretend that we haven’t been here before.

Choosing Between Vital Parts is a Losing Proposition for I/DD

When it comes to full lives for Oregonians with intellectual and developmental disabilities, we want it all.  As a member of the Oregon I/DD Coalition, OSSA helped to identify four top priorities for the 2015 legislative budgeting session.  These four priorities, together, represent a pathway to richer lives for Oregonians with I/DD.  The four priorities are:

• DSP Wages: Raise the wage for Direct Support Professionals.
• Brokerage and CDDP Workload Model Budget:  Fund workload model at proposed 95% equity for CDDPs and Brokerages.
• Fairview Trust:  Keep the promise of community housing opportunities for people with IDD and restore the Fairview Trust.
• Employment: Continue funding to improve employment outcomes for people with IDD.

These priorities are listed in no particular order, for one very important reason: we cannot possibly weight one over the other if we are truly in support of people with intellectual and developmental disabilities.  Together, these elements of community employment, quality support professionals, community housing, and high-quality case management work together in a person’s life.  Each makes the other possible.

When I think about trying to prioritize our four adopted budget goals, it seems to me that I’d be choosing between the “neck” of the system (our case management force, connecting people to vital resources) or the “head” of the system (the resources people need to create full lives).  The head will not prosper without a neck; employment services, housing services, and provider organizations will not prosper without a strong case management force to navigate people to engage with them.  Likewise, the neck is pointless without a head; case management services are pointless without the employment, housing, and provider resources to which we can direct customers.  Choosing between vital parts is a losing proposition for the I/DD body.

(public domain source)

Choosing between equally critical services, or offering one to be cut over another, is a non-starter for the OSSA.  However, this does not mean that OSSA is unwilling to engage in the process of tough decision-making, should it be required at DHS.  The Office of Developmental Disabilities has new, dedicated, and promising leadership in Director Lilia Teninty.  We do not ask her to make hard decisions in a vacuum, but instead are willing to provide important education on the impacts and ramifications of various options as they are considered.  We do not wish to instruct, but we are happy to support, the budgeting activities of ODDS.

OSSA sees an incredible opportunity at hand for the many components of the Oregon I/DD community to develop a strong, cohesive presence at the capitol.  Our strength is in the purity of our collective goal: to promote quality service and supports which respectfully further the rights, equality, justice, and inclusion for all Oregonians with intellectual and developmental disabilities and their families.

The Time for Advocacy is Now!

Distressing news out of the capitol: lawmakers may be looking to cut $140 million from human services in order to fund a budget “hole.”  The question is, what does a $140 million cut to human services look like?  Though plan hours are not likely to be cut, vulnerable areas include provider pay rates and Brokerage funding for Personal Agents.  Brokerage Personal Agents and direct support providers have worked to implement dozens of system changes over the past two years.  With these changes has come a lot of additional workload and responsibilities, which is already cutting into the bottom line: time spent with Brokerage customers.  Any reduction in funding is going to cut further into that time.

The sun is shining on lawmakers at Oregon’s Capitol Building.

Now is the perfect time to flex your advocacy muscles.  Advocacy is defined as “the act of pleading or arguing in favor of something, such as a cause, idea, or policy,” and if you’re a human, chances are you’ve been engaging in advocacy your entire life.  Some people are certainly more comfortable speaking their minds than others.  The trick to being a good advocate isn’t about becoming a perfect speaker, it’s about finding the right message for you.  When you find a cause or idea that is true to your heart and soul, you will find that the words flow much more easily.

How have your Brokerage services helped you to live the life that you choose?  Please call, email, or visit your state representatives and senators, and let them know how important your Brokerage services are to you!  For more information, check out the Oregon I/DD Coalition’s special bulletin on the current need for advocacy.  You can find your legislators, and see the list of legislators on the Ways and Means Subcommittee on Human Services, the joint committee in charge of making legislative budget recommendations.  You can also get talking points and more information about each of the Coalition’s four priorities: Employment, restoring the Fairview Housing Trust, raising DSP wages, and funding Brokerage and county case management at 95%.  Each of the four priorities were selected because they fund the cornerstones of a full and meaningful life in Oregon’s communities.

Even small cuts to the 95% Case Management funding mean losses for Brokerages from last biennium, at a time when workload has greatly increased.  Let your legislators know that overworked/underfunded PAs mean that you can’t get the services you want, when you want them.  Urge them to fund the Workload Model for Brokerages and counties at 95%!

DD Awareness Event Honors Margaret Theisen as DD Champion

“I Have Something to Say” poster, and model Maddie Zielinski

Last Friday March 6th, the Oregon Council on Developmental Disabilities hosted the 2015 DD Awareness Celebration kickoff event.  As part of the festivities, attendees enjoyed guest speakers Robin Shobe and state DD Director Lilia Teninty, and the unveiling of the 2015 DD Awareness poster “I Have Something to Say,” highlighting adaptive technology, with participation from poster model Maddie Zielinski.  Sherri Osburn, Vice Chair of the Oregon Council, served as emcee, and Senator Sara Gelser read a message to the community from Governor Kate Brown.

Senator Gelser also presented awards to this year’s DD Champion recipients, Jim Wrigley of Disability Rights Oregon, Margaret Theisen of Full Access, and Trisha Baxter of DHS.  Bob Joondeph of Disability Rights Oregon accepted the award on behalf of Jim Wrigley, who was unavailable. All three recipients have been pillars of the DD Community, and their retirements create a call to action for those who remain to try to fill their roles.

Margaret Theisen accepts DD Champion award from Sherri Osburn and San. Sara Gelser.

Margaret’s introduction rightly spoke of the leadership and inspiration she has provided to the Brokerage community, and to the broader I/DD community.  Her focus on self-determination for the people with I/DD that we serve never wavers.  Margaret has demonstrated in her daily work that we cannot compromise on core values.  She has been the person in the room who is willing to say the unpopular thing, the uncomfortable thing, and in doing so, often what matters most.  Margaret is set to retire from Full Access in June, where she has served as Executive Director for 13 years.