Second Washtenaw CMH Town Hall Meeting Scheduled
Recent Updates on Community Living Supports (CLS) and Self-Determination
Thursday, May 7, 2015
5:30 to 7:00 P.M.
St. Luke Lutheran Church
4205 Washtenaw Ave
(near the intersection of US 23 and Washtenaw Ave.)
Ann Arbor, MI 48108
Click here to download a printable flyer
In response to the Town Hall Meeting held on April 14, 2015, the following items are posted on the WCHO Website:
Washtenaw County Customer Service e-mail
Washtenaw County Behavioral Health Task Force FAQ on the future of the WCHO (Washtenaw Community Health Organization)
CLS PowerPoint Presentation from the 4/14/15 meeting (open from this page on the WCHO Website ; click on Townhall/CLS Announcement)
CLS FAQ
Washtenaw County Legislators
Thursday, April 30, 2015
From Upstate NY : “Our families will not be silenced”
This is an editorial by Cheryl Englert, the mother of a son with disabilities and a special education teacher from rural Upstate New York: “Insights: Our families will not be silenced”, 4/11/15.
After more than 30 years of working to see that New York state provides necessary supports to meet the needs of men and women with disabilities at work and in their homes, Cheryl Englert sees all that hard work being undone:
“While our local representatives have been supportive, Gov. Cuomo is turning his back on our most vulnerable citizens. Examples include a plan to close all sheltered work centers within six years, and a decree that actually prohibits new workshop employment right now. On the residential front, he has vetoed four bills that would have begun to address an expanding list of individuals who await housing because their family members are growing too old to effectively care for them."
Cheryl’s son Matt has a good life living in a 4-person home that provides 24-hour/day care to him and his best friends. He also works and socializes at a local sheltered work center. His mother can no longer speak confidently to the other mothers she talks to that those opportunities will continue to be available.
“The lack of choices and opportunities has had drastic effects on those families. It is like flying into a storm where you cannot see where you are going or how long will it take to reach the sunshine…”
But they will not be silenced:
“Right now, hundreds of us across the state are writing letters and making phone calls to our elected representatives. We are organizing and expanding activism efforts, such as The Arc’s Family Advocacy Group (www.lwarc.org) — all in the name of better lives for individuals with disabilities and their families. It’s time to get this great state back on track!”
Read the whole article here.
Monday, April 27, 2015
More on ND : Rationale for approving community-based services in proximity to an institution
The rationale given below could also apply to any congregate setting of 4 or more individuals with disabilities who live or participate in activities together, including people with autism and other disabilities who live in planned communities. This is believed to be the first ruling by the CMS using the “heightened scrutiny” review.
The North Dakota plan, on pages 27 and 28, includes these responses to commenters:
“One commenter disagrees with the Department [North Dakota Department of Human Services] determination that Aged and Disabled adult residential care settings can fully comply while serving between 10 and 36 individuals each, contending that even with remedial strategies and timelines just based on size these are ‘mini institutions’. Commenter believes … that individuals should be able to receive service in their own home or apartment.”
Response from DHS: “As stated in the CMS’s summary of these regulations, the intent of the HCBS settings rule is to create a more outcome-oriented definition of home and community-based settings, rather than one based solely on a setting’s location, geography, or physical characteristics. When assessing compliance of adult residential service settings DHS focused on the recipient’s experience rather than the size of the facility. Individuals can access other wavered services to meet their assessed needs. Consumers and their families make the decisions about what type of services they wish to participate in and who will provide the care; including the decision to use residential services.”
...
“…on-site visits were conducted of the settings in question which validated the Department’s position that these settings are not isolating and do have HCBS qualities and characteristics. Some individuals living on the grounds of the State ICF have been unable to successfully secure housing or services off the grounds of the State ICF, which is less restrictive than living in the State ICF. Other individuals/guardians have made the choice, including tours/visits, to determine if they would like to move…”
Response to two more commenters opposing HCBS funding on the grounds of an ICF/IID:
“In addition to the information provided in the Statewide Transition Plan …on-site visits were conducted of the settings in question which validated the Department’s position that these settings are not isolating and do have HCB qualities an characteristics. The individuals are assessed at least annually to determine if alternate service settings are available and are afforded the choice, including tours/visits, to determine if the would like to receive services at another location….”
See the Coalition for Community Choice
VOR's Weekly E-Mail Update
Objections from advocacy organizations
Saturday, April 25, 2015
Federal agency allows community-based services and housing on the grounds of an institution
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North Dakota recently received approval from the Centers for Medicare & Medicaid Services (CMS) to provide Medicaid Home and Community-Based Waiver funded residential housing and day services on the grounds of the North Dakota Life Skills and Transition Center (LSTC), a state funded intermediate care facility (ICF/IID). [IID = Individuals with Intellectual Disabilities]
Federal approval for housing and day services on the ICF/IID campus came after a heightened scrutiny review by CMS, as required by the federal "community" regulation which requires all HCBS-funded services meet specific criteria. The proximity of the housing and day services on the campus of an ICF triggered "heightened scrutiny."
This is believed to be the first ruling under a heightened scrutiny review. The North Dakota Protection and Advocacy Project, North Dakota Center for Persons with Disabilities, and The Arc of North Dakota sent a letter registering their significant upset and opposition to the ruling and for not being involved as “stakeholders.”
Read their letter to CMS here.
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From Questions and Answers Regarding Home and Community-Based Settings
[page 7] Question: Are settings on the grounds of or adjacent to “private” institutions considered not to be home and community-gassed (HCB)?
Answer: It depends. Settings that are on the grounds of or adjacent to a private institution are not automatically presumed to have the characteristics of an institution. However, if the setting isolates the individual from the boarder community or otherwise has the characteristics of an institution or fails to meet the characteristics of a home and communit-based setting, the setting would not e considered to be compliant with the regulation. States will need to assure that these settings fully comply with the requirements…to qualify for Medicaid reimbursement under 1915(c), (i), or (k) as noted in the transition plan. A state’s assessment of settings that isolate should be informed by the public comments received prior to submission of the transition plan. Also, states may elect to adopt more stringent settings characteristics that would not allow a setting to be on the grounds of a private institution….
Read more from CMS on the new rule here.
Friday, April 24, 2015
MI Mental Health System, Including Services to DD, Severely Impacted by Funding Cuts
The problems with state funding of Community Mental Health (CMH) services, including services to the developmentally disabled population, are complex. I am no expert on Mental health funding and it is likely that my take on it is not entirely correct, but this is what I think has happened based on news articles:
- Michigan's Medicaid expansion (Healthy Michigan) began enrolling participants in April of 2014;
- The State expected a large influx of federal funds to pay for health care to eligible citizens through Medicaid expansion and on that basis made large cuts to state Medicaid funding and to non-Medicaid General Funds that local agencies use to fill in the gaps for people not in the Medicaid system.
- The State also adjusted payments to counties to make funding more evenly consistent throughout the state, resulting in some counties receiving more Medicaid funding and some less than before.
- Large increases in people insured by Healthy Michigan and decreases in numbers insured by "regular" Medicaid have resulted in less funding for regular Medicaid mental health services, at the same time that the numbers served by the CMH system have increased. (Apparently, the two Medicaid systems are funded separately).
- The Governor's desire to use the increased Medicaid funding from the federal government as savings for future costs to the State, has made less money available to pay for current services.
- The legislature's expectation of increased federal funding to cover current and future costs was overly optimistic.
"Cuts likely necessary for Oakland’s Mental Health Authority, with $11M deficit", 4/7/15: $11million deficit...cuts to providers, programs, and layoffs likely…$14million reduction in Medicaid dollars from the state….some providers could go out of business…worst-case scenario - more cuts in 2016 fiscal year.
Kent County’s Community Mental Health authority Network 180 press release [no link available], 4/8/15: Board votes to implement agency-wide cuts…salary cuts…”adults with DD will see a dramatic reduction in daily support and services immediately”…new lower Medicaid rates in West Michigan to increase rates in other parts of the state…affected by unexpected drop in traditional Medicaid enrollment with introduction of Healthy Michigan (Medicaid expansion).
“Cuts threaten services for Oakland Co. disabled” 9/24/14: 2014-15 budget includes $20million in state aid cuts to general fund and $14million in cuts from Medicaid…Changes under the Affordable Health Care Act - “Michigan opened Medicaid to nearly 500,000 additional residents and moved their health care costs—including mental health care costs —off the state’s books and on to federal rolls”…..In anticipation of savings, state trimmed $75million from mental health spending for 2014-15 fiscal year…some cuts offset by federal dollars…number of people served by Michigan’s CMH system climbed from 184,708 in 2004 to 248,189 last year [2013]…
“Funding cuts send hundreds of mentally ill onto Detroit’s streets” 5/1/14: Detroit’s longtime round-the-clock homeless shelter turns out hundreds of people…no place to go…when state lawmakers passed Medicaid expansion, an infusion of federal funds was expected to make up for cuts based on anticipated savings…general fund dollars also cut…CEO of Detroit CMH on state plan: “It’s like, next month you need to pay the mortgage, and the state says, ‘Well your grandmother may die in the next six months and leave you the money.'”
“Local mental health programs face cuts” from Northern Lakes Community Mental Health Blog, 4/3/14 : “Community mental health groups across the state began to lose roughly 54 percent of their state-funded general purpose money on Tuesday, the same day enrollment in the Healthy Michigan Plan opened.” [General fund dollars, as opposed to Medicaid dollars serve people who do not qualify for Medicaid but nevertheless have needs served by the mental health system such as children, people on Medicare, and many people who are mentally ill.]
“Adult Foster Care Aid May be at Risk, Advocates Say” 5/30/14 from Kaiser Health News/Detroit News: “As part of major changes associated with the health care overhaul, also known as Obamacare, Michigan opened Medicaid to nearly 500,000 additional residents. That moves their health care costs — including mental health — off the state’s books and onto the federal government’s.”…state trimmed mental health spending for the current fiscal year [2013-14]by $75 million, Snyder wants to trim more…”The state’s not going to save as much as they think they are.”…Gov. wants most of the annual savings to cover future Medicaid costs…
“Michigan community mental health centers turning away patients, blame ‘flaw’ in Medicaid expansion” from mlive.com, 4/22/14 : “Local mental health officials say Gov. Rick Snyder's administration overestimated the savings from Healthy Michigan [Michigan's Medicaid expansion], resulting in a funding shortfall for CMH boards across the state.”…”While overall funding has increased, CMH programs are still left with funding gaps because the Healthy Michigan dollars can't be used to fund services for those who don't have Healthy Michigan coverage.”…”Vizena [from the association of CMH Boards] said he had hoped the state would have done a better job to make sure there wasn't a time gap between losing the general fund money and getting an influx of money through new Healthy Michigan enrollees”.
“Macomb, St. Clair County CMH cut services” 4/29/14: “Macomb County CMH is cutting services to about 1,350 people. St. Clair County Community Mental Health is cutting services to approximately 300 people. Sanilac County CMH is cutting services to about 90 people.”…St. Clair County uses the general fund money to cover people on Medicare...Medicare covers only about 80 percent of the cost of mental health services, the rest of which the CMH covers with general fund monies….general funds help cover “spend downs”, deductibles before insurance kicks in….
“Proposed mental health funding cuts could hurt Jackson’s uninsured, mentally ill population” from mlivd.com, 1/6/14: Maribeth Leonard, the CEO of Jackson County's mental health agency LifeWays - legislators are assuming too much under the expansion…In 2013, LifeWays served 2,780 patients who were uninsured or not covered under Medicaid with general fund dollars…
Tuesday, April 21, 2015
Benefit Events for High Point School, Ann Arbor, MI
The Fabulous Kiwanis High Point Spaghetti Dinner
CANCELLED due to building problem.
Rescheduled for Wednesday, May 13th, 2015
Wednesday, April 22, 20151835 S. Wagner Rd.
Ann Arbor, MI 48103
Dinner @ 5:30 - 7:30 p.m.
Tickets: $7 for adults, $3 for children, $20 for a family of four
- Dinner Music featuring the Saline Fiddlers
- Karaoke
- Silent Auction
Catch up with old friends, make new friends, and have fun!
Contact: Cathy Zahina at 734-716-3434, czahina@yahoo.com
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High Point School
Fundraiser at Nicola’s Books
April 23—29, 2015Shop at Nicola’s Books any time Thursday, April 23 through Wednesday, April 29 and say that you want your purchases to earn books for High Point School.
20% of what you spend on books, toys, games, scarves, bags, candles, and decorative items will be given to High Point School to buy books.
Shop for books you love and help your school get books it needs.
Westgate Shopping Plaza
2513 Jackson Ave, Ann Arbor
734-662-0600
www.nicolasbooks.com
Summary of 4/14/15 meeting on community living services in Washtenaw County, MI
The meeting was attended by about 100 [make that 180!] people eager to hear whether the WCHO [facing a budget deficit of $3.8 million] and CSTS had plans to cut services that allow individuals and their families to survive and thrive in community settings.
The meeting began with a PowerPoint presentation on “Utilization Management”, a fancy term for assuring that public funds are spent for the purposes intended by law and policy. The full presentation can be linked to here on the WCHO Website. [Click on “Town Hall Announcement” and then “CLS PowerPoint Presentation”] . The emphasis was on “medically necessary” services and a plan to review and evaluate Individual Plans of Service (IPOS’s), looking at those plans with the highest utilization rate first. These reviews may or may not result in cuts to services for individuals.
There was nothing new as far as CMH agencies' obligation to be fiscally responsible and to provide Medicaid services that are "medically necessary". Here is a blog post from The DD News Blog with the definition of medical necessity. The definition does not limit recipients of services to what would ordinarily be considered strictly medical services. It includes services to maintain or improve functioning and allow a person to live in the community.
As is usually the case, the most interesting part of a public meeting is the public and the questions and observations of people who went out of their way to attend the meeting. Here are some of the issues that were raised by the crowd:
The letter that went out to recipients of services under “Self-determiniation” arrangements announcing a decrease in the pay rate for direct service providers:
- This was not the main topic of the 4/14 meeting, but the explanation for decreasing the pay was that Washtenaw County wants pay rates to conform to rates in the other counties in the 4-county affiliation of the Community Mental Health Partnership of Southeast Michigan.
- Someone pointed out that there is no requirement that pay rates for every county be the same and that Washtenaw has the highest cost of living in the four-county region.
- It is ironic that pay rates for direct service providers under self-determination living arrangements are being cut, while the Federal government through its rule on Home and Community-Based service settings encourages these kinds of living arrangements over congregate care and is applying pressure on states to move in this direction. Cutting pay rates is a sure way of making it harder for individuals to hire direct care staff who are competent and reliable.
There were also complaints that families were already being threatened with service cuts, including people needing care and supervision 24 hours a day. Some were told there was no appeal of service cuts, even though there is both a local and state appeals process required by law. For more information see Recipient Rights and page 24 and 25 of the Guide to Services.
More meetings:
Check the announcements page of the WCHO Website for more information on a meeting scheduled for May 7, 2015 at St. Luke Lutheran Church in Ann Arbor.
The WCHO Board of Directors meets on the third Tuessday of every month.
The new pay rates for direct care workers for Self-determination go into effect on May 15, 2015, but there will be a meeting before that date to discuss concerns of consumers.
Tuesday, April 14, 2015
Washtenaw County, MI : CMH to announce rate decrease for Community Living Services
Update 4/16/15: About 100 people attended the WCHO/CSTS meeting on Tuesday, April 14, 2015 to discuss Community Living Services and potential cuts in services when they are found on further evaluation to not meet "medical necessity" criteria. The above letter was for people who hire providers through "Self-determination" arrangements. Although this was not the main subject of the meeting, it did come up. There will be future meetings on the "Self-determination" decision and on other Community Living Services. Stay tuned.
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The Washtenaw Community Health Organization and Community Supports and Treatment Services are holding a meeting tonight to discuss plans affecting Community Living Supports for people with disabilities. These include staffing for people in their own homes.
According to a letter sent to consumers (individuals with disabilities and their families who receive services), the rate of pay for these direct care workers will be reduced to $13.88 per hour, which includes worker’s compensation, transportation, community participation, taxes, and training. The letter says that “While this is not a reduction in your current level of services, it may reduce the amount you can pay staff.” WCHO also encourages consumers to meet with their clinical teams and consider options, “including the option to use one of our contracted providers for CLS services”.
The change will go into effect on May 15, 2015.
People whose services are funded through Medicaid Waivers, especially those with exceptionally high needs, find themselves extremely limited by the allowable amount of funding available to pay service providers. The higher the needs, the more skilled and reliable direct care workers need to be to fulfill those needs. Reducing the hourly wage of workers who, if they do their jobs well, take on tremendous responsibility to do difficult work leads to diminishing returns: a high turnover rate, poorer care, and sometimes no care at all.
The change in rate is justified as “necessary to ensure that Washtenaw County’s rate is the same as our regional partners and to ensure that we are being fiscally responsible.” Another way of looking at it is that both these things might be accomplished by raising the rate of our regional partners and ensuring a more stable and reliable workforce all the way around.
Friday, April 10, 2015
Groundbreaking Survey of Families of Adults with DD
I’m not often quoted in press releases, but this has to do with a committee that I chair for VOR. We conducted a survey that gathered perspectives of families of individuals with profound disabilities who receive care in Medicaid Intermediate Care Facilities (ICFs) or in home and community-based settings.
VOR is a national nonprofit organization that advocates for individuals with intellectual and developmental disabilities, including autism. We are the only national organization that advocates for a full range of residential and service options for people with intellectual and developmental disabilities, including own home, community-based, and larger settings, such as licensed Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID).
Here is the press release for the survey report.
VOR represents a large number of families whose family members have severe to profound disabilities that are complicated by the presence of multiple disabilities, medical fragility, or severe behavioral challenges. Many, but not all, live in institutional settings, and have needs that are often overwhelming for families and smaller community settings such as group homes. We were able to gather responses from families and guardians in thirty states, representing 117 Intermediate Care Facilities (ICF/IID) and compare them with responses from families and guardians of people who lived in smaller community homes.
Individuals who live in Medicaid-funded ICFs/IDD receive an institutional level of care. As a bundled service program, Medicaid ICF settings provide a set of services according to a standardized set of guidelines across the nation. The “Social Security Act created this benefit to fund ‘institutions’ (4 or more residents) for individuals with intellectual disabilities, and specifies that these institutions must provide ‘active treatment,’ as defined by the Secretary” [Centers for Medicare & Medicaid Services(CMS)].
The conclusions we reached from the survey results were:
- The responses to the ICF survey revealed a sharp contrast between common misperceptions of “institutions” as segregating and isolating environments and the perceptions of family members and guardians of individuals living in these settings.
- Based on their own experiences, ICF respondents indicated a high level of satisfaction with their individuals’ ICF homes, staff competency, access to services and community integration.
- Non-ICF respondents expressed general satisfaction in measures relating to integration, access to services, staff competency, and vocational opportunities but were evenly divided over whether their individuals would do poorly or well in an ICF as an alternative setting. ICF respondents by a strong majority believed that their individual would do poorly in a non-ICF community setting.
- Most respondents for both surveys were informed about alternatives to their individuals’ current placements based on their own evaluations of different settings and, in some cases, the individuals’ prior placements in other settings.
“What would you like our government to know about the current move to de-institutionalize ICF residents in favor of small community-based facilities?”
What mattered most to families of those receiving care in both ICF and Non-ICF settings was that their family members with I/DD received the care they needed and that their right to individual choice was respected. As so aptly stated by one respondent –
“Good public policies should be based on experience, common sense and humanity. There should be deference and respect for the positions of families who have first-hand experience in the care and treatment of persons with life-long disabilities” (ICF Survey respondent).
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About VOR
from the Nonprofit Quarterly, July 2014: "People as Pendulums: Deinstitutionalization and People with Intellectual and Developmental Disabilities" by Tamie Hopp, VOR Director of Government Relations & Advocacy
Thursday, April 9, 2015
Michigan: Aacorn Farm - Expanding Choices, Building Community
Check out the Website for Aacorn Farm, an innovative agricultural community for adults with autism and other disabilities. It has an especially good "newsroom" with up-to-date information on autism.
Are innovative programs for people with autism and other developmental disabilities going to fall victim to the pressure by the federal government and federally-funded advocacy organizations to deny people with DD access to specialized residential and service options? See more about intentional communities and choice at the Coalition for Community Choice .
Wednesday, April 1, 2015
No Joke : Job Consultant concedes that the comatose are not good candidates for integrated employment!
One of the people interviewed was Michael Callahan, who argues that community employment is “achievable for almost everyone…”. He goes on to say, “So bring me a person who’s in a coma and let’s agree right now until they get out of the coma we won’t try to get them a job," But anyone short of comatose is a likely candidate for a minimum wage job in the community. Did I mention that Michael Callahan makes his living as president of a consulting firm (Marc Gold & Associates) that, among other things, finds integrated employment for people with disabilities?
The NCPR story includes interviews with people who welcome the closure of sheltered workshops and others, including people who work in these specialized work centers, who say they fill a vital need in their communities.
This is very personal for me, because my two sons, who are not comatose, are nevertheless profoundly limited by their multiple disabilities. Their needs are great: along with 24/7 care, they need activities and social relationships with with people who accept and respect them for who they are. But that does not include working at a job that pays minimum wage. I always wonder about people who say they could place anyone not in a coma successfully in a job with the proper supports. With unlimited funding and effort, supporting my sons in employment is still unimaginable. What are they doing this for? To make a point? To prove that their ideology that says everyone can be employed in the community is true?
I have a question for Mike Callahan and this is not a joke, either. By his way of thinking, how can he justify dismissing the employability of a person in a coma? We know that some people in comas are aware of their surroundings and eventually recover. Is it fair to exclude the comatose from the opportunity to work in supported employment in the community?
The NCPR story is worth listening to, but the report begins with a misleading statement about the basis for closing sheltered workshops. This is a common blunder that reporters make when they do not check out source materials and instead rely on what they are told.
The NCPR report begins with this statement: “The United States Supreme Court ruled that keeping people with disabilities in separate work settings constitutes discrimination more than 15 years ago..." This is not true. Every reporter who wants to talk about the 1999 Supreme Court Olmstead decision should be required to read it. The court in Olmstead did not mention sheltered workshops. The case is about two women in Georgia who were at one time institutionalized, but wanted to receive services in a community setting. They were deemed capable of this by the professionals who treated them and community-based services were adequate to their needs. The court determined that unjustified isolation is discrimination under the Americans with Disabilities Act (ADA). But the court also recognized "...that nothing in the ADA or its implementing regulations condones termination of institutional settings for persons unable to handle or benefit from community settings...Nor is there any federal requirement that community based treatment be imposed on patients who do not desire it." The ADA requires that programs are provided in the most integrated setting appropriate to the needs of the individual.
I wouldn’t have to worry that the services and programs that my sons need might be eliminated by overzealous disability advocates, if we had proper enforcement of the Olmstead decision. Unfortunately, Olmstead is being used for purposes never intended by the Supreme Court, as a tool to help states close programs, eliminate residential options, and relieve the states of responsibility for people with more severe disabilities under the guise of preventing discrimination.
[This post was tweaked and updated later in the day, 4/1/15...JB]
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