1. Community Supports Workload Overview Prepared for Stearns County Human Services Board March 24, 2015

2. Community Supports Division Purpose: o Support and enhance the quality of life for older people and people with disabilities. Improve dignity, health, and independence. Promote choice in how clients receive services and live their lives. Reason for today’s presentation: o Stearns County residents not receiving quality service due to Community Supports workload exceeding resources (staff and management) o Unable to implement MnCHOICES o Cumulative effect of several issues 2

3. Reasons for workload increase 1. MnCHOICES: ◦ Mandated program for counties ◦ MnCHOICES determines eligibility and initial support plan for several publicly funded home and community supports programs, including Medical Assistance waivers and personal care assistance (PCA) ◦ Actual visit time and indirect time take considerably longer than assessments it replaces ◦ Stearns “launched” in July 2014; unsuccessful in completing most new assessments due to staffing issues ◦ Three additional full time equivalents (FTEs) authorized – two for 2014, one for 2015 (conservative) ◦ Reassessments to be implemented during 2015; Stearns does not have staffing capacity 3

4. Reasons for workload increase 2. Changes in public assistance: ◦ No longer time in Community Supports to help clients understand and assist them through the application / reapplication process ◦ No longer able to stay up to date on changing regulations 4

5. Reasons for workload increase: 3. Escalating caseloads (examples): Number of persons open in Community Supports as of 12/31/14 (8.6% increase in two years) 20122986 20133154 20153243 Disability/elderly caseload averages per worker: 200355 cases 201575 cases Adult Protection (58% increase since 2010 with no additional staff) YearTotal reports Reports forwarded for adult protection response 2010417317 2011489372 2012568432 2013605492 2014634500 5

6. Reasons for workload increase 4. County responsibility for PCA appeals ◦ March 1, 2014 per notice from Department of Human Services (DHS), counties became responsible for preparing and submitting appeal summaries related to PCA services, and for appearing at appeal hearings 5. Structured Decision Making for adult protection ◦ Effective in 2013, legislation required counties to utilize specific practices and tools in working with reports of vulnerable adult maltreatment. This added time; we have not been able to fully implement all practices. 6

7. Reasons for workload increase 6. Services to new Americans ◦ Stearns County is home to many new Americans, specifically a high number of persons originally from Somalia. Due to cultural and language considerations, services take longer. 7. Rates Management System (RMS) ◦ DHS developed a statewide standardized waiver rates management system (RMS) effective 1/1/14. This involves considerably more work for staff than previous rate setting. 7

8. Reasons for workload increase: 8. Provider enrollment by DHS ◦ Effective January 1, 2014, the Minnesota Department of Human Services assumed responsibility for waiver service provider contracts. There was no longer a county ‘grid’ of providers. Staff need to research information in more complex, hard to understand systems. 8

9. Reasons for workload increase 9. Person-centered / community-focused approach ◦ The federal government and state are requiring changes in approach to providing services to persons with disabilities. In 1999, the Supreme Court Olmstead Decision ruled it is unlawful to keep people with disabilities in segregated institutional settings when they can live in a community setting. ◦ Corporate foster care moratorium in place ◦ The federal rules for Home and Community-Based Services (HCBS) will be changing – leading to changes in service system that will require more time by case managers to arrange eligible services. ◦ Person-centered takes time! 9

10. Reasons for workload increase: 10. Increased and frequently changing complex regulations (examples) ◦ Frequent cost of living adjustments (COLAs) in 2014 ◦ Frequent new instructional videoconferences and bulletins/emails with complex information and changes to be made 10

11. Reasons for workload increase 11. 245D and Rule 40 ◦ Minnesota Statute 245D – “Home and Community-Based Service Standards” enacted in 2013/2014 created/changed additional licensure standards for currently licensed services and added several additional services, with impact on case management as well. ◦ Minnesota Rules (“Rule 40”) is changing from aversive and deprivation procedure concept to positive behavioral support concept. Providers reluctant to accept difficult clients. 12. Increased waiver allocations ◦ = increased need for case management 11

12. Reasons for workload increase: 13. Additional programs / responsibilities ◦ Moving home Minnesota (MHM) and Essential Community Supports (ECS) – small, but detailed 14. Increased client complexity / expectations ◦ More persons with severe mental illness on waivers ◦ Increased expectations from disability advocates ◦ Need to deny services based on rules = unhappy customers ◦ More appeals and need to explain decisions 12

13. Reasons for workload increase: 15. Less capacity in State Operated Services (SOS) system ◦ More pressure to discharge clients from Anoka Metro and St. Peter Regional Treatment Centers (RTC) ◦ County staff responsible for arranging community service; costs county $25,000 per month once client determined to no longer need RTC level of care ◦ Staff don’t have time to develop alternatives 13

14. Comments from waiver review (week long, on site review by DHS - June 2014) Recommendation: Adopt strategies to reduce current caseloads. This may include hiring additional staff, redeploying current staff, or contracting for case management with private agencies. With already high caseloads that will continue to grow for continually changing programs, administering the waiver programs and providing quality case management has become more complicated. In the Elderly Waiver (EW) and Alternative Care (AC) programs, program enrollment increased by 145 cases, or 29%, from 2008 to 2012. In the CAC, CADI, and BI programs, program enrollment increased by 27 cases, or 7%, and growth occurred in participants with mental health needs and higher medical needs. 14 CAC= Community Alternative Care; CADI= Community Alternatives for Disabled Individuals; BI= Brain Injury

15. Comments from waiver review (week long, on site review by DHS - June 2014) Recommendation (continued) : Finally, in the Developmental Disabilities (DD) waiver, the program grew by 17 participants or 5.5% from 2008 to 2012. Stearns County currently has very high caseloads in the disability waiver programs compared to other lead agencies across the state. It is difficult for staff to stay current on program requirements, and case managers are in need of additional supports. Other lead agencies report success with contracted case management services, as it can help cut down on travel time for participants living outside the region, provide flexibility for added or reduced lead agency caseload needs, and provide culturally appropriate services. 15

16. Units: Developmental disabilities Disabilities / chemical dependency Mental health Senior services and adult protection Unit caseloads include assessments for new clients, ongoing visits, and handling client emergencies (loss of housing, mental or physical health decompensation, abuse/neglect, etc.) 16

17. Developmental Disabilities (DD) Unit: Major functionsStaffing DD waiver case management / DD screenings “Rule 185” case management MnCHOICES for persons with cognitive impairments (new assessments) Additional need: 5.0 FTEs 6.0 FTEs 2.0 FTEs (in process) Total: 13 FTEs 3.0 FTEs (MnCHOICES assessments, reassessments, DD waiver case management) 17

18. Disability/Chemical Dependency (CD) unit: Major functionsStaffing CAC, CADI, BI waiver management / Long Term Care Consultations PCA assessments MnCHOICES assessments for persons under age 65 (new assessments) Chemical dependency assessments Additional need: 7.0 FTEs 1.0 FTE 3.0 FTEs (in process) 3.0 FTEs Total: 14 FTEs 2.0 FTEs (MnCHOICES assessments, reassessments, CAC/CADI/BI waiver case management) 18

19. Senior services / adult protection unit: Major functionsStaffing Adult protection Elderly Waiver and community well case management / Long Term Care Consultations PCA assessments Alternative Care case management MnCHOICES assessments for age 65+ (new assessments) Additional need: 1.5 FTEs 10.5 FTEs (7.0 for MCOs) 0.5 FTEs 3.0 FTEs (in process) Total: 16.0 FTEs 2.0 FTEs (2.0 MnCHOICES assessments/reassessments, EW case management) 19

20. Summary 7.0 additional FTEs needed 20

21. Potential solutions: A. Hire additional new staff Considerations: o Having county staff can provide more seamless service o Office space is an issue o Takes time to recruit and hire o Potential for layoffs if things change o Revenue-producing positions o At some point need more supervisors o “Phase 2” of previous Board discussion may apply 21

22. Potential solutions B. Discontinue all or some contracts with Managed Care Organizations (MCOs) Background: In 2005, the Board entered into contracts with pre-paid Medical Assistance managed care plans – Blue Plus, Medica, and UCare. The county contracted to provide county staff to provide assessment and care coordination for MCO members eligible for the Elderly Waiver as well as the “community well” population. This was at a time when state law transferred responsibility for the Elderly Waiver to MCOs, for clients enrolled in MCOs. (All persons age 65+ eligible for Medical Assistance currently must now enroll in a MCO.) (continued) 22

23. Potential solutions B. Discontinue all or some contracts with Managed Care Organizations Excerpt from 8/2/05 Board item: Staff are requesting policy direction to move forward in developing contracts with health plans, if terms can be developed to ensure that reimbursement to the county cover in full, services to be provided. The primary reasons for pursuing contracting are:  The need for continuity of services for Elderly Waiver clients during this transition  Dual eligibles are a high risk population due to low income levels, and from a public health/adult protection standpoint, counties should remain involved with this population  The need for continuity for persons who transfer from the Alternative Care programs to the Elderly Waiver  The need for continuity for providers who have current contracts with the county (continued) 23

24. Potential solutions B. Discontinue all or some contracts with Managed Care Organizations Considerations: o Non-mandated service o Need to give 4-6 months notice; may require temporary staff in interim o Once done, county has no further responsibility o May have concerns from elderly residents about change o Loss of job satisfaction for staff who work with MCOs / this clientele (continued) 24

25. Potential solutions B. Discontinue all or some contracts with Managed Care Organizations Considerations: o Time intensive service with three MCOs (each with different procedures, annual audits) o Bumping up against staffing maximums in contracts – will need to hire additional staff to continue o MCO work is fully supported with MCO revenue; it is anticipated that redeployed positions will continue to be revenue-producing through other funding streams 25

26. Potential solutions C. Continue to explore additional services to contract out or discontinue. 26