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.

binoculars

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.

planning for the future

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.

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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.

Disintegrating-DollarSpending  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

January 2016 deserves a second look.

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.

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)

(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.