Review of the 2022 Disability Policy Webinar Series from the ARC Michigan

I have been in semi-hibernation during the COVID pandemic and have not been following state and local disability policy as closely as I should. With regard to policy affecting people with Intellectual and Developmental Disabilities (I/DD) and their families, one way to catch up is to follow the ARC Michigan’s 2022 Disability Public Policy Webinar Series on Zoom. The Webinars are held every Friday in June with each week featuring a different topic and speakers. The Webinars are also archived for viewing later.

I have my differences with the ARC and other large advocacy organizations. Too often they do not represent the spectrum of views held by people with disabilities and their families. Many policy makers find it convenient to accept the views of well-funded advocacy groups as a proxy for individuals with I/DD and their families, thereby avoiding controversy and the unsettling reality of differences of opinion that they would otherwise have to confront. Nevertheless, the ARC policy seminar offers a variety of topics and includes knowledgeable speakers on state and federal issues affecting people with disabilities.

The ARC Michigan 2022 Public Policy Webinar #1: June 3rd, 2022

ThIs is the PDF handout for the first Webinar with Belinda Hawks from the Behavioral Health and Physical Health & Aging Services Administration (BHPHASA), Remi Romanowski-Pfeiffer from TBD Solutions, and Al Jansen, Senior Advisor to Director Hertel, Michigan Department of Health and Human Services (MDHHS)

This is the link to the Youtube video of the Webinar.  

The BHPHASA is new. It is the result of combining agencies under the MDHHS. 

From the Website:

“The Health and Aging Services Administration (HASA) was created under Executive Order 2021-14 combining Aging and Adult Services Agency and Medical Services Administration under one umbrella within MDHHS. Michigan's Medicaid Office is also part of HASA and the designated State Unit on Aging function will be fulfilled by HASA.”

The topics that I was especially interested in include the Direct Care Workers (DCW) crisis and the “Heightened Scrutiny” of settings receiving HCBS (Home and Community-Based Services) funding to assure that they provide access to “the community” based on the wishes and needs of the people living in these settings. There are other issues that will also be of interest to providers, local agencies, and people with disabilities, such as how the state is planning for recovery from the COVID pandemic and various scenarios to consider.

The Direct Care Workers (DCW) crisis - Allen Jansen, Senior to Elizabeth Hertel Allen Jansen, Senior Advisor to Elizabeth Hertel, Director of the MDHHS.

[Allen Jansen’s presentation begins at around 43 minutes on the Youtube video.]

National Data on DCWs (also known as DSPs or Direct Service Providers):

• 4.5 million direct care workers in the U.S.
• 40 to 60% rate of turnover
• 84% have no retirement benefits
• In 2019, 53% were women of color
• 47% qualify for public funded benefits
• In 2020, $20,200 was the median income
• By 2030, the predicted shortage of DCWs will be 151,000.

Michigan has a shortage of 36,000 care workers out of a workforce of approximately 165,000.

A state Direct Care Task Force has been created to establish priorities and make recommendations to the state. 

Also involved in discussions is the Quality Improvement Council (QIC). 

From the Website:

“The Quality Improvement Council directs the development and implementation of the behavioral health managed care programs and serves as the primary point of prioritization and integration of quality improvement activities.

“The Quality Improvement Council includes quality and administrative staff representatives from MDHHS, the PIHPs, CMHSPs, provider organizations, quality vendors and advocacy members.”

There are many job titles that fall under the broadly defined category of Direct Care Worker. Current efforts focus on improving wages and benefits for DCWs. The broad strategy for improvement includes establishing competency standards for the professionalization of the DCW workforce, designing a career pathway, elevating the value of DCWs (specifically identifying them as providing an essential service), and collecting data to demonstrate their impact:

The Governor’s proposed 2023 budget includes funding to stabilize DCW wages. At the time of the Webinar, a supplemental budget that includes additional wages for DCWs was stalled. 

Recommendations for improvement include setting a starting wage at $17 - $18/hour for DCWs and adjusting funding to cover added expenses to providers to pay supervisory personnel.

There is also a proposal to expand “residential models”. Belinda Hawks clarified that this is referring to the need for facilities to house people who are stuck in emergency rooms and hospitals with no place to go or are in nursing homes and want to get out. These would be home environments aligned with a psychiatric treatment facility model. The estimated need for such facilities is 48 beds for adults and 12 for children. 

“Heightened Scrutiny”

Heightened scrutiny is a process to determine whether a setting receiving HCBS funds allows sufficient access to the community to be eligible of funding under the CMS (Centers for Medicare and Medicaid Services) settings rule. 

Michigan does not set limits on the size of a setting. According to Belinda Hawks, no settings so far have been determined to be ineligible. The state is still reviewing settings. Compliance with the settings rule must be complete by March 2023. The Department expects to be finished reviewing settings by August or September 2022 to give providers enough time to make changes to comply or find other arrangements for residents of these settings. 

Providers have been notified if they under the HS process. The final determination is up to CMS.

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See also:  

DCW commentary from ARC Michigan

Michigan’s mental health system is failing many with severe autism
Thursday, May 16, 2019

Budget Alert from the Michigan Assisted Living Association (MALA)

This is from the Michigan Assisted Living Association (MALA) on increasing wages for direct care workers who provide services to people with developmental disabilities as well as those who are aging or have mental illness or physical disabilities. 

The only thing I would change about this appeal is to make sure it applies to direct care workers regardless of where the individual served lives. Workers in group homes, nursing homes, and other settings are as vital to the care of people with disabilities as those who are hired to work in the individual's own home.

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MALA Budget Alert - Your Action is Needed Now!

Your advocacy is urgently needed as the Michigan Legislature works on the state budget for the fiscal year beginning October 1, 2022. Please see the message and link below for you to communicate with your state legislators.

The behavioral health coalition, of which MALA is a member, is urging the Michigan Legislature to appropriate an additional $127.0 million in General Fund dollars. This funding equates to an approximate $4.00 per hour wage increase which would be in addition to the $2.35 per hour wage increase.

We expect the $2.35 per hour wage increase to be funded in the next fiscal year’s state budget. However, the potential exists for an additional wage increase particularly if the state revenue estimates released later this month are positive.

Please take a few minutes to contact your state legislators to urge their support for the additional funding referenced in the message below. An additional $4.00 per hour wage increase would result in an estimated average starting wage rate state-wide of $18.00 per hour for direct support staff. 

Please feel free to contact us if you have any questions related to this MALA Budget Alert.

ROBERT L. STEIN

General Counsel
, 734-525-2400, 
rstein@miassistedliving.org
 

KATHLEEN M. MURPHY


General Counsel
, 734-525-2401, 
kmurphy@miassistedliving.org

BRENDA L. ROBERTS


Director of Quality Assurance and Education, 
734-525-2407, 
broberts@miassistedliving.org

Please Support Michigan’s Direct Care Workers

When a Michigan resident experiences a mental illness or developmental disability, they should be able to hire the help they need to ensure their safety and wellbeing. But right now, they can’t.

In today’s tight labor market, it is difficult to find a Direct Care Worker, whether you are looking for care for yourself, a loved one, or hiring an employee for your agency. This leaves our state’s most vulnerable residents at risk.

Our coalition proposes a General Fund appropriation of $127.0 million in FY 23 which would increase the average starting wage rate in the behavioral health system to approximately $18.00 per hour. That’s what many entry-level jobs pay across the state right now and is the least we can do to compensate our Direct Care workforce.

With significant amounts of GF dollars and pandemic-related federal funding available to the state right now, Michigan has a once-in-a-lifetime opportunity to address the long-standing direct care workforce crisis in a meaningful and sustained manner.

Let’s reach out and make it happen.
 

Click Here

Service provider's plea to Michigan to maintain increased wages for direct care workers

Bridge Magazine,"Michigan’s nonpartisan, nonprofit news source", published an opinion piece by Darren Hodgdon, the CEO of Beacon Specialized Living, a care provider serving individuals with disabilities and mental health needs at over 80 locations across Michigan. 

 The article, "Michigan must keep the wage supplement for direct care workers", 4/27/21, urges the State to make permanent a temporary supplemental wage increase of $2.25/hour for direct care workers who work with people with disabilities, mental illness, the elderly, and others with disabilities.  Covid has exacerbated a problem that already existed:

"While the $2.25 supplemental wage increase currently allows providers such as Beacon to offer a starting wage of $12.50, this is still below what other states are funding and it is only temporary – set to expire again at the end of September. Mental health providers statewide are calling for permanent enactment of the wage increase on an ongoing basis per Gov. Gretchen Whitmer’s Fiscal Year 2021-2022 Budget Recommendation. We also need a clear return to work policy and funding support to help cover the costly weekly testing of employees who may refuse vaccination.

"There are high costs associated with not providing adequate access to specialized mental health services, including detriments to quality of life, uncompensated emergency care, lack of medication compliance and increased hospitalizations. This permanent funding is a vital step to ensuring sustainability and retaining caregivers as they shoulder the critical, but challenging, work of caring for one of Michigan’s most vulnerable populations."

As the economy heats up, as it is expected to do, better paying and easier jobs will become available. There is good reason to believe that many direct care workers, even those who love their jobs and are dedicated to helping people with disabilities, will join the exodus of workers from this difficult and unappreciated profession.  

Hodgdon continues,

"Our citizens and communities simply cannot afford the ramifications of letting this additional pay disappear. It would also recognize the awe-inspiring and critical work these caregivers provide to Michiganders with severe mental illness, developmental disabilities, chronic disease, or substance abuse disorders who rely on this care."

Michigan Direct Care Workers for People with Disabilities are Facing a Cut in Pay

Michigan Direct Care workers were given a pittance of a wage increase of $2 per hour to continue providing care to people with developmental and other disabilities during the Covid Pandemic. It helped, but now direct care workers will be losing even that if the state does not move to fund these workers.

An opinion piece from Bridge Michigan, “Michigan direct care workers, families headed for choppy waters” by Robert Stein, Todd Culver, and Robert White, 12/02/20, warns of what lies ahead if state government does nothing to prevent this undermining of an already fragile system of care for people with disabilities.

Robert Stein is general counsel of the Michigan Assisted Living Association, Todd Culver is CEO of Incompass Michigan and Robert White is a parent advocate.

Here are some excerpts:

"Many people are approaching the end of 2020 with a sense of relief and hope for a better new year. But for those Michigan families who care for someone with a mental illness or developmental disability, Jan. 1, 2021 is a day fraught with dread.

"That’s the date Michigan’s budget will no longer provide its $2 hourly pay increase for the direct care workers these families rely upon. As a result, they may lose the help and support they need to manage their busy households, continue their employment and ensure the best possible help for their loved ones." 

Last Spring, “more than $100 million in federal funds was matched by a generous $40 million in state appropriations to ensure ongoing direct care worker support.” 

“…The work our state’s direct care workers do is arduous, important and noble, and their positive impact is widespread, with over one million Michiganders relying upon the support direct care workers provide.“

If nothing happens, direct care workers will receive a cut in pay. 

“This will exacerbate Michigan’s direct care worker shortage. Current turnover in the field already is a staggering 37 percent and growing. Meanwhile, demand for the services these workers provide has never been higher. The COVID-19 pandemic and all the stress and uncertainty it has produced has undoubtedly strained the collective mental health of Michiganders, and families throughout the state are struggling to deal with the fallout.“

...“Direct care worker salaries are tied to state Medicaid funding, which, at present, are exceedingly low. Today’s workers currently receive, on average, a starting wage of $10.70 per hour, with many receiving minimal or no additional health or other benefits. When one considers that the average starting wage at a retail outlet or a fast-food restaurant is typically anywhere from $11 to $14 per hour, it’s clear to see that we can and must do better for Michigan’s direct care workforce. “

As we know, COVID-19 has not gone away and neither has the burden on people with disabilities, their families, and direct care workers to maintain some sense of normality and hope for the future. Direct care workers’ wages “…should continue to reflect the extraordinary responsibility they bear. “ 

“We urge state policy leaders to act before the end of the year to continue the funding needed to extend the $2 per hour as a permanent increase through 2021 to ensure the well-being of everyone.”

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This is a good time to figure out who your state legislators are, if you do not already know, and keep those contacts available for the year ahead. You may get to know individual aides who work for legislators and the governor and have an easier time of getting your message across.

Here are some useful contacts:

Contact the Governor 

Find your state representative

Find your state senator

 Update from a FaceBook comment: "The gov's office submitted a supplemental budget request on 12/3, one of the items is an extension of the $2/hr increase through March 31. Still a drip-drip-drip approach, but better than cutting it at the end of the month."

Michigan workers eligible for tuition-free community college and more unemployment benefits

According to an article on Mlive.com, "Michigan front-line workers eligible for tuition-free community college under state program", 9/10/20, by Lauren Gibbons:

"Michigan residents without college degrees who’ve worked through the COVID-19 pandemic can now apply for tuition-free community college, Gov. Gretchen Whitmer announced Thursday morning.

"The Future for Frontliners program, initially announced by the governor in April, is open to workers without an associate or bachelor’s degree who were deemed essential during the COVID-19 pandemic.

"To be eligible, workers must have worked at least part-time for 11 of the 13 weeks between April 1 and June 30 and were required by their job to work outside their home at least some of the time.

"The program is funded by $24 million from the Governor’s Education Emergency Relief, part of the federal funding Michigan received from the CARES Act, according to a press release from the governor’s office. The state estimates 625,000 workers could be eligible for the program...."

In addition, according to another Detroit Free Press article, "State of Michigan: Unemployed workers will receive $300 federal benefit within 10 days" by Adrienne Roberts, 9/10/20:

"Michigan workers filing for unemployment benefits will receive the extra $300 federal benefit within 10 days, the state's Unemployment Insurance Agency said Thursday.

"The payments are retroactive, and will be paid out for the weeks ending Aug. 1, Aug. 8 and Aug. 15 initially, Steve Gray, the director of the UIA, said in a release.

"The benefit, funded by the Federal Emergency Management Agency (FEMA), is available to states for up to six weeks, which would end Sept. 5. The UIA has applied for the additional three weeks of funding, according to the release..."

For details, read the full article and this update from the Michigan Unemployment Insurance Agency.

Michigan: more information on pay increases for Direct Care Workers

This is a letter from the Michigan Department of Health and Human Services, Behavioral Health and Developmental Disabilities Administration, to PIHPs (regional administrative agencies that pass on Medicaid funding to local Community Mental Health agencies).

It deals with proposed Medicaid funding changes that have not been approved yet by CMS (the Federal Centers for Medicare and Medicaid Services) and are subject to change.
 
"...The purpose for sharing this information is to let you know what we are working on and to keep you as informed as we can as we all work to manage this crisis...."
 
*************************** 
April 30, 2020

TO: Executive Directors of Prepaid Inpatient Health Plans (PIHPs) and Community Mental Health Services Programs (CMHSPs)
 
FROM: Jeffery L. Wieferich, M.A., LLP, Director JW
Bureau of Community Based Services
Behavioral Health and Developmental Disabilities Administration

SUBJECT: Funding Information
 
[See the full letter here. It is missing its original formatting, but is the best I can do for now.]
 
Excerpt on pay increase:

Direct Care Wage Increase
The Direct Care Wage increase is intended to be effective from April 1, 2020 to June 30, 2020. [emphasis added] The increase does have limited funding and a limited scope of which workers are included. The behavioral health direct care workers impacted by this increase include those providing:

• Community Living Supports
• Overnight Health and Safety Supports
• Personal Care
• Prevocational Services
• Respite
• Skill Building.

There will be a Medicaid L-letter coming out shortly with this information.

The wage increase will be pushed out through the PIHPs in the same manner as the last two wage increases and funding will support the $2 an hour increase along with an additional 12% employer cost.

Please let us know if you have any questions.

cc: Allen Jansen

Washtenaw County: Disability Town Hall on Impact of the Direct Care Worker Shortage on PWD

Saturday, June 15th, 2019, 10:30 a.m. - 12:30 p.m.

Washtenaw Community College

Morris Lawrence Building, Room 101

4800 E. Huron River Drive, Ann Arbor, MI

"Inadequate wages, tied to Medicaid funding, have created a Direct Care Worker shortage. Provider agencies cannot compete with other businesses that offer higher wages. People with disabilities rely on direct care workers for essential support services to access their communities. This is ours to fix."

Next steps? Actions to take?

Panelists: [State] Senator Jeff Irwin; [State] Representative Yousef Rabhi; Robert Stein - MALA; Laura De Palma - Caring Majority

RSVP appreciated: kgrant@communityalliance.com

Legislative Forum on the Direct Care Worker Crisis in Michigan

This announcement is from the CMHAM (Community Mental Health Association of Michigan) Weekly Update for March 29, 2019:

"Coalition Announces Legislative Forum on Michigan’s Direct Care Worker Crisis A group of statewide advocacy organizations, including the CMH Association of Michigan, is holding a legislative forum to highlight the state’s direct care worker crisis. The details of the event are provided below."

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LEGISLATIVE FORUM ABOUT THE DIRECT CARE WORKER CRISIS IN MICHIGAN!

WHEN: FRIDAY, APRIL 12, 2019, 8:30-10:00 AM

WHERE: IN THE GRAND ROOM OF THE KENT ISD EDUCATIONAL SERVICE CENTER

2930 Knapp St NE, Grand Rapids, MI 49525 PARKING IN LOT #11

WHY: 50,000 DIRECT CARE WORKERS ARE NEEDED TO PROVIDE CRUCIAL SUPPORTS AND SERVICES TO INDIVIDUALS WHO HAVE A MENTAL ILLNESS AND/OR DEVELOPMENTAL DISABILITY. THE COMMUNITY MENTAL HEALTH SYSTEM ALONE PROVIDES SERVICES TO APPROXIMATELY 300,000 MICHIGAN CONSTITUENTS. THIS SYSTEM DIRECTLY OR INDIRECTLY IMPACTS MORE THAN TWO MILLION MICHIGAN CITIZENS.

Inadequate wages, which are tied to Medicaid funding, have created a Direct Care Worker shortage. Turnover rates average 37%, and providers cannot compete with other businesses that offer higher wages, often with fewer work demands. People with disabilities who rely on direct care workers for essential supports are unable to access their communities, attend college, work and live full lives.

To RSVP and/or request more information or a reasonable accommodation, please contact Salli Christenson at 800 292-7851, ext. 130 or salli.c@arcmi.org

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Here are more CMHAM weekly updates

From the CMHAM Website: 

"The Community Mental Health Association of Michigan (CMHAM) is the state association representing the state’s public Community Mental Health (CMH) centers, the public Prepaid Inpatient Health Plans (PIHP) public health plans formed and governed by the CMH centers) and the providers within the CMH and PIHP provider networks..."

Michigan minimum wage increase and new paid sick leave requirements go into effect

These should help improve working conditions for Direct Support Professionals who work with people with disabilities, but they don’t go nearly far enough to stabilize the workforce. For people making more than minimum wage, the increase theoretically puts upward pressure on all low wage jobs.

The Michigan minimum wage has increased from $9.25/hour to $9.45/hour. An article form the Detroit Free Press, “Michigan paid sick leave changes: What to know about new law” by Micah Walker, 3/29/19, explains the new sick leave law.

These policies would have been more generous had the voters been allowed to vote on a proposed minimum wage increase and if a paid sick leave policy that was approved by voters had not been not been almost gutted during the lame duck legislature in December 2018.

“The paid sick leave law comes after activists gathered enough signatures to get the issue on the Nov. 6 ballot. However, instead of allowing it to go on the ballot, Republicans in the Legislature adopted the proposals in September and two days after the November election introduced bills to gut the laws they had passed just a few months earlier. If the proposals had gone to the ballot and passed by voters, it would have taken a three-fourths majority to amend the laws.”

The sick-leave law applies to workplaces with 50 or more employees, which includes full-time and some part-time employees with a lot of exemptions allowed.

Employees can take paid leave for:

• A physical or mental illness, injury, or health condition affecting themselves or a family member.
• Medical diagnosis, care, or treatment of themselves or a family member
• Preventive care for themselves or a family member
• If the employee or a family member is the victim of sexual assault or domestic violence
• For the closure of the employee's place of business by order of a public official
• To care for a child whose school or daycare has closed by a public official
• The employee's or a family member's exposure to a contagious disease
• To relocate
• To obtain legal services

The Act requires an employer to pay employees at a rate equal to or greater than the normal hourly wage, base wage, or minimum wage. The employer does not have to include overtime, vacation, bonuses, commissions, supplemental pay, price-rate pay or gratuities when calculating the pay rate. 

Read the article for more details.

Michigan's Direct Care Worker Staffing Crisis

Michigan’s Community Mental Health system serves people with intellectual and developmental disabilities, mental illness and substance use disorders. Crain's Detroit Business featured an article on 10/21/18 on the "Staffing Crisis of direct care mental health workers faces clients, families" by Jay Greene. The article covers a Crain’s health summit panel that was chaired by Robert Stein, the general counsel for the Michigan Assisted Living Association (MALA). MALA represents providers of assisted living and similar services including mental health services to people with developmental and other disabilities. [note: direct care workers are also known as Direct Support Professional or DSPs.]

According to Stein, “We have a real crisis with support services to people with disabilities…Wage levels are not competitive with retail companies, fast food restaurants and others. The funding levels have been constrained for many years.”

A MALA survey found “the average turnover rate for agencies providing staff is 37 percent, the starting wage is $10.46 per hour and the average number of open positions for full-time staff is 12 percent, 20 percent for part-time staff.”

Although the legislature “approved $64 million in additional funding in the fiscal 2018 budget to increase the average hourly rate by 50 cents..”, the panel characterized this as a “drop in the bucket”.

The article quotes Robert White, a parent advocate who has two adult sons with autism, as commenting that "Paying [direct service professional] $2 above the minimum wage (of $10 per hour) prevents more people from leaving the system. …We also need a supplemental budget in the lame duck session and future budgets to come [that] must have non-negotiated budget items. We can't kick the can down the road. It is an infrastructure requirement, a civil and constitutional right to have these services like good roads, good education and clean water to drink." [emphasis added]

Here is a quote from State Rep. Christine Greig, D-Farmington Hills, the Michigan House Democratic Floor Leader:

"I get really frustrated by state government and how we fund things,…We talk about integration. We should be talking about great quality care, not about money. You start from an outcomes standpoint. What does the provider, patient need in services. The money flows from that."

[I agree, and I wish more legislators and advocates would support this approach to funding services, rather than promoting the idea that full inclusion in the “community” is the highest and only worthwhile goal of our our system of services.]

The panel also discussed the kinds of things that direct care givers do:

Robert White says in response: ”My older son has high medical needs, 24-7 supervision, in taking the meds he needs, bathing ... nutrition, safety, socialization in the community…The home he is in is currently understaffed. Managers are actively taking shifts. Many caregivers work many shifts. There is mental and physical fatigue, possible errors. It is not their fault. They are truly their lifeline."

John Williams, executive director of Progressive Lifestyles Inc., pointed out that "A lot of staff work two and three jobs. It is unattractive to get involved. …in many cases, it is a very physical job with wide spectrum of disabilities. One day you will lift somebody from a wheelchair to a bed. (The next day) help people move in, repair a stove, fix a washing machine. It's a very demanding job."

According to the article, Stein said MALA and others are “starting a grass roots effort to lobby state legislators to add a line item in the Medicaid supplemental budget that would amount to an increase of 75 cents per hour.”

PA: Fix the Direct Support Professionals Crisis

See Fix the Direct Support Crisis

By the numbers:

• Direct Support Professionals (DSPs) in Pennsylvania make an average wage of $11.54/hour. They provide daily support to people with intellectual disabilities and autism. 
• $11.54/hour is $4 per hour less than a living wage for a working family in Pennsylvania. 
• The turnover rate of DSPs is 26.9% (over 8,500 DSPs every year) and the vacancy rate for DSPs is 12.1% (over 3,500 DSPs per year). 
• The Commonwealth of Pennsylvania is the sole funder of the wages of DSPs. The state budget has grown by over $6.3 billion since 2009, but the rate increases and DSP wages have flatlined. 

This crisis is nationwide.

New York: The NY Assembly Minority Task Force Report on Developmental Disabilities

The New York state Assembly, the lower house of the New York Legislature, is dominated by a 62 vote supermajority of Democrats. The Assembly Minority (Republican) Task Force on Protecting the Rights of People with Developmental Disabilities has recently issued a report based on the testimony of parents, people with disabilities, advocates, service providers and other interested parties on services for people with developmental disabilities in New York state. Forums were held at eleven sites throughout the state, attracting crowds of 25 to 85 people who came to have their say on problems they had experienced with the service system for people with DD.

The task force heard a diversity of opinions representing people with varying degrees of disability and need for services. The name of the report is C.A.R.E.S. (Championing Aid, Rights, Equality, and Services: a Report on the Olmstead Decision & Its Impact on the State’s Developmental Disability Community). A number of complaints centered on the state’s misinterpretation of the 1999 U.S. Supreme Court Olmstead decision. Many families and advocates for choice have been criticizing the use of Olmstead as a weapon to close programs and services that are considered “too institutional” by some, but are nevertheless highly valued and needed by a significant portion of the DD population and their families. The C.A.R.E.S. report addresses this issue at both the state and the federal level and calls for the state to revaluate its interpretation.

The recommendations that come out of the report are a logical and compassionate response to the problems that are heard again and again in many areas of the country: preserve, restore, and expand the services that people with DD want and need, compensate service providers with the funds they need to provide the best possible services, pay direct care workers enough to maintain a high quality and sustainable work force, and protect the rights of all people with DD to appropriate levels of service based on their needs and preferences.

I question why these recommendations come only from the minority in the legislature and why they are not at least bipartisan, if not universally supported by legislators who have surely heard from some of their constituents about the growing problems within the DD system of services. 

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The following is the Executive Summary from the C.A.R.E.S. report: 

EXECUTIVE SUMMARY

The Assembly Minority Task Force on Protecting the Rights of People with Developmental Disabilities was formed in response to numerous calls and complaints from constituents to members of the Assembly Minority Conference concerning the announcement by the governor that sheltered workshops would be closed in order to bring New York State into compliance with the federal Department of Justice’s interpretation of the U.S. Supreme Court’s Olmstead Decision. The term sheltered workshop refers to an organization or environment (typically a business) that employs people with disabilities in a “sheltered” environment. The overarching decision required states to place persons with mental disabilities in community settings rather than in institutions. However, people have argued, there were several factors to the requirement of moving individuals to community settings that state governments, including New York, have overlooked. With this in mind, the Assembly Minority Conference conducted a series of statewide hearings to gather information from parents, service providers and individuals with developmental disabilities to determine if there are policy changes that can be made or new laws that can be enacted to help provide for people with developmental disabilities in the most caring and cost-effective manner possible.

Among those with firsthand experience, the belief that there has been a misinterpretation of the Olmstead Decision has caused a ripple effect throughout the developmental disability community as it pertains to the integration of employment and how individuals will find and get to employment outside of sheltered workshops. To meet the state’s requirements, sheltered workshops have changed their business models to incorporate non-disabled individuals into the workforce. This change has raised questions as to what happens to individuals in the developmental disability community who worked in these former sheltered workshops who can no longer perform their jobs in these facilities.

The deinstitutionalization requirements of the Olmstead Decision also impact housing for the developmental disability community. While many individuals live with their families, parents are concerned with what will happen to their children when they can no longer care for them or they should die. While New York State’s Office for People with Developmental Disabilities (OPWDD) conducted a survey of individuals who contacted the agency with concerns about housing for their family members, their findings do not seem to help those who are actually looking for housing. A prominent finding in the “Residential Request List” (RRL) report by OPWDD concludes that there is enough housing for the 11,000 who want housing statewide, but this may not benefit each individual locally.

Numerous issues were raised during the Task Force’s forums. This report outlines some of the major problems that the developmental disability community is dealing with, including jobs and housing; services for families; and salaries and compensation for those who work with individuals with disabilities.

******************************************************
Recommendations

This is a summary of the recommendations of the Minority Task Force from the Website of Assemblyman Clifford Crouch, Chairman of the task force:

• Requiring the Attorney General to reevaluate the state’s interpretation of the Olmstead Decision. 
• Working with the federal government to prevent the state from losing funding as a result of the interpretation of the Olmstead Decision. 
• Create post-schooling training programs for individuals with developmental disabilities to better prepare them for employment. 
• Create incentives for sheltered workshops to hire individuals without developmental disabilities. 
• Create a Bill of Rights for Individuals with Developmental Disabilities to outline in statute their rights. 
• Fully fund the increase in minimum wage for direct care workers employed by non-profit providers. 
• Create a commission to study and report on what wage levels would need to be in order to recruit and retain an adequate number of qualified direct care workers in the various regions of the state, with a special focus on making sure that staffing levels are adequate for the transition to integrated employment. 

Crouch noted that New York State’s minimum wage is set to increase to $15 an hour in most parts of the state by 2021. The task force was concerned about the repercussions this could have on the developmental disability community’s direct care workforce.

MI Advocates Support Wage Increase of $1/hour for Direct Support Workers

Below is an alert from MALA, the Michigan Assisted Living Association, in conjunction with the Partnership for Fair Caregiver Wages. These organizations are requesting that you urge the Michigan Governor and Lt. Governor to support a $1/hour wage increase for direct support workers throughout the state. Those are the people who work directly with our loved ones in all kinds of settings. Anyone who is receiving support services through a community mental health agency is probably aware of the difficulty in finding and keeping people who provide high quality care and direct support. Low wages for these workers is a nationwide problem that has reached crisis proportions. "It is estimated that a Medicaid gross appropriation of $90 million would provide this wage increase."

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Governor to Release Budget Recommendations on February 8 – Your Advocacy is Needed!

MALA is providing this urgent budget alert to request your immediate assistance in advocating for additional Medicaid funding to increase staff wages. Governor Rick Snyder will be announcing his executive budget recommendations for the October 1, 2017-18 fiscal year on February 8. MALA and other members of the Partnership for Fair Caregiver Wages met with the Governor’s office and the State Budget Director in November to discuss the staffing crisis in the public mental health system.

We urge you to send letters today to the Governor, Lt. Governor and MDHHS Director. Download their contact information. Also download talking points for your letters.

The Partnership’s recommendation is for a $1.00 per hour wage increase in the next fiscal year for direct support workers throughout the state. It is estimated that a Medicaid gross appropriation of $90 million would provide this wage increase.

Please act now and feel free to call or e-mail us if you have any questions regarding this urgent budget alert.

ROBERT L. STEIN
General Counsel
1-800-482-0118 ext. 2400
rstein@miassistedliving.org

KATHLEEN M. MURPHY
General Counsel
1-800-482-0118 ext. 2401
kmurphy@miassistedliving.org

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Talking Points 

−A staffing crisis currently exists in the recruitment and retention of direct support workers providing Medicaid mental health services throughout the state. These services include community living supports, personal care, skill building and supported employment. 

− The Interim Report of the 298 Facilitation Workgroup includes Section 7 on workforce training, quality and retention. This Section specifically indicates that all Affinity Group participants recommended raising the wages and benefits of direct care staff. 

− The Section 1009 Report developed as a result of boilerplate language in the 2015-16 state budget bill recommends a starting wage of $2.00 per hour above the minimum wage, or $10.90 per hour. 

− The Partnership for Fair Caregiver Wages conducted a survey in August 2016. The survey findings included an average starting wage statewide for direct support staff of $9.30 per hour. The average turnover rate in this survey is 40%. 

− Low staff wage levels and high turnover rates have an adverse impact upon the continuity of services and quality of life for people with disabilities funded through the public mental health system. 

− It is strongly recommended that additional Medicaid funding of $90 million be appropriated in the 2017-18 budget for the Michigan Department of Health and Human Services. This funding would provide for a staff wage increase of $1.00 per hour.

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See also the "1009 report" Executive Summary

Contact Information

Governor Rick Snyder 

P.O. Box 30013 

Lansing, Michigan 48909 

Phone: 517-335-7858 

Online contact information – www.michigan.gov/snyder 

Click on Contact the Governor and Share Your Opinion 

Lt. Governor Brian Calley 

P.O. Box 30013 

Lansing, Michigan 48909 

Phone: 517-373-3400 

E-mail: brian.calley@michigan.gov 

Nick Lyon

Director Michigan Department of Health and Human Services 

333 S. Grand Ave. 

P.O. Box 30195 

Lansing, Michigan 48909

Fraud and abuse in the Medicaid Personal Care Services program

“Stunning” is the word that comes up most often to describe this week’s election. 

The GOP has promised to repeal Obamacare with few detailed plans, as yet, to replace it or preserve parts that have worked and are generally popular. This uncertain future makes it hard to comment on policy regarding Medicaid-funded healthcare and caregiving for people with DD. Nevertheless, an article, “Report Finds Caregiver Fraud Widespread” by Melissa Bailey, 11/8/16, that examines Medicaid in-home Personal Care Services is relevant for now and will continue to be relevant as long as these services are publicly funded. [The article appeared in Kaiser Health News (KHN) and was republished by Disability Scoop.]

According to the article, the Medicaid Personal Care Services program (known as Home Help Services in Michigan) is “rife with financial scams, some of which threaten patient safety…” A report from the Office of Inspector General (OIG) for the US Department of Health and Human Services recommends that the federal Centers for Medicare and Medicaid Services (CMS) improve oversight and monitoring of the program "...to prevent and detect improper payments, facilitate enforcement efforts, and reduce the risk of beneficiaries being exposed to substandard or otherwise harmful care.” 

Personal Care Services “provide non-medical assistance to the elderly, people with disabilities, and individuals with chronic or temporary conditions so that they can remain in their homes and communities. Typically, an attendant provides PCS. In many States, PCS attendants work for personal care agencies, which are enrolled in the Medicaid program and bill for services on the attendants' behalf…”

More from the KHN article:

“The OIG has investigated over 200 cases of fraud and abuse since 2012 in the program, which is paid for by the federal government and administered by each state. These caretakers, often untrained and largely unregulated, are paid an average of $10 per hour to help vulnerable people with daily tasks like bathing, cleaning and cooking.

“The report exposes vulnerabilities in a system that more people will rely on as baby boomers age. Demand for personal care assistants is projected to grow by 26 percent over the next 10 years — an increase of roughly half a million workers — according to the U.S. Department of Labor.

“‘This type of industry is ripe for fraud,’ warned Lynne Keilman-Cruz, a program manager at Alaska’s Department of Health and Social Services who has investigated widespread fraud. The risks increase because the care takes place out of view in people’s homes, and because neglected patients may not advocate for their own care.”

The OIG report calls on CMS to “establish national qualifications, including background checks, and ensure every claim identifies the worker and time of service. It also called on CMS to require states to enroll all personal assistants, so they can be tracked by unique numbers.” These are all sensible recommendations to reduce fraud and protect Medicaid beneficiaries. 

CMS, however, is “treading lightly” in deference to disability groups who fear that stricter regulations may limit beneficiaries’ access to caretakers. This fear is not unfounded, but why are disability advocates willing to trade access to caretakers for the perpetuation of abusive and fraudulent practices that undermine the program and risk the safety of people with disabilities? Is it too much to ask advocates who claim to represent our family members with disabilities to take a stand in favor of both access and high quality care? 

Instead of mandatory background checks and training for Personal Care Services, CMS has opted to give $50 million in grants to 26 states to set up background check programs. Instead of requiring mandatory training, CMS has offered states the option of offering basic caretaker training “without usurping beneficiary decisions on what skills are most appropriate for their home care workers”. These measures may be a step in the right direction, but why not require training specified in a plan of care based on individual need and preference, rather than leaving it up to chance as to whether the home care worker has the skills to do the job he or she is hired to do?

Here are excerpts from another article from Kaiser Health News on California’s In-Home Supportive Services Programs,  “Lots Of Responsibility For In-Home Care Providers — But No Training Required” by Anna Gorman, 1/6/15:

“No overall training is required for the more than 400,000 caregivers in California’s $7.3 billion In-Home Supportive Services Program (IHSS) for low-income elderly and disabled residents. Without instruction even in CPR or first aid, these caregivers can quickly become overwhelmed and their sick or disabled clients can get hurt, according to interviews with caregivers, advocates and elder abuse experts.”

…

"IHSS was never intended to be a medical program. The caregivers are distinct from visiting nurses and the certified home health aides often dispatched after a hospital stay. IHSS caregivers are not certified or licensed and are hired to do personal care and household tasks.

“But more than a quarter of IHSS clients are 80 or over, and many have chronic health conditions or dementia. In these and other cases, caregivers can end up providing basic medical care–helping to administer insulin shots, manage other medication or dress wounds, for instance.”

Here again the issue of training is controversial:

“A union that represents caregivers ... sees advantages to a minimum level of training.

“SEIU-United Healthcare Workers West proposed a statewide initiative last year that would have required 75 hours of training, but the union didn’t get enough signatures to put the measure on the ballot. SEIU plans to try again for the 2016 ballot.

“Requiring training would ‘save lives,’ said Loretta Jackson, who serves on the union’s executive board and is an IHSS caregiver in Sacramento. It would also reduce the risk of injuries to caregivers, she added.”

But disability advocates balk at requirements that might threaten access to caregivers. 

“Eileen Carroll, the deputy director of the California Department of Social Services, said the program doesn’t have a lot of training requirements because it was set up to give clients the choice of how they want their care delivered.”…

“Carroll said the state is in a tough situation. Training is a positive thing, she said, 'but you have a very strong adult disabled community in this program who … oppose any mandatory training.’

"Many disability rights advocates say a training mandate would make it more difficult for IHSS consumers to find caregivers, chip away at clients’ autonomy and drain resources from the program.

“‘The idea of choice is really paramount,’ said Deborah Doctor, legislative advocate at Disability Rights California. ‘Anything that puts a requirement that erodes that choice is a problem.’”

Again, why not tie the training for the home care worker to the individual needs of the person receiving care with that person’s participation in determining what is needed? That way the appropriate level of training would be provided leading to both access and higher quality care without compromising the beneficiary's right to choice.

The cost of improving the Personal Care Services program is the unspoken issue influencing the CMS decision on whether to impose higher standards on states to better ensure the safety of people needing care. These costs also stoke the fear of disability advocates that access to caregivers will be adversely affected. 

Is it too much to ask of federal regulators, state agencies, and especially disability advocates to take a more nuanced approach to the costs and benefits of a system that reduces abuse and delivers better care to those receiving services? It may be that having higher standards reduces many costs over time. And if it costs more to deliver better care and avoid the tragic consequences of allowing abuses of the system to continue, this may be a cost that the public is willing to bear. After all, more and more families are affected by the responsibility of taking care of aging and disabled family members and would rather see a system that provides higher quality care that they can rely on, than one that limps along failing to provide even a basic level of care that protects their loved ones from harm.