Monday, August 30, 2004

The Problem with Providers

OK. I am a service provider, director of a regional center vendor agency. I confess. The concern regarding any reforms proposed by service providers, whether regional center vendors or regional centers themselves, is that our bright visions of the future tend to be better funded, less restricted versions of the present. The idea is almost always that if we were given the funds and the freedom to do what we now do for the people we now serve the lot of people with disabilities would improve.

This denies the central question about this system- are the people it serves getting the best possible most appropriate support. There's something anti-evolutionary about the premise that agencies need to thrive for people with developmental disabilities to do so. What about people who are poorly served, not only because of staff turnover or poor qualifications but also because the agencies serving them are philosophically unable to keep pace? I know that better wages for direct care staff would expedite the progress of clients. I suspect that the disappearance of some agencies would as well.

One question with no clear answer- could the elimination of underperforming agencies and their overhead free up enough resources to provide for better funding of well-performing agencies and a general improvement of the support people with disabillities receive? It is possible when you consider how many millions of dollars go to agency infrastructure and real estate that the closure of a few large site-based agencies could release significant funding back into the community. Whether or not that helps depends on whether the agencies do, and how much.

The purpose of reform needs to always be to sustain the progress being made by people with developmental disabilities. On the survival of service providers, even the service providers should be agnostic.

Wednesday, August 18, 2004

Regional Center Operations and System Reform

Today's topic: Things to think about when considering the Regional Center's role in our system, or, Why I have no friends in this world.

During California's lengthening budget debacle, the most common cost-containment proposals coming from vendor groups have advocated for reducing the size and scope of Regional Center operations. There are some important reasons that these proposals deserve a cautious response.

Primer paragraph: In California's community-based system of support to people with developmental disabilities, the legislature budgets funds to support the system which are allocated to the Department of Developmental Services (DDS.) DDS contracts with 21 private (more on "private" later) non-profit agencies, called Regional Centers (RCs) which have sole dominion for the provision of non-institutional services within a catchment area. The funding provided through those contracts is divided between Purchase of Service (POS) funds which must be spent on direct support through outside vendors and Operations which are intended to pay for those activities performed by Regional Center staff and which may be diverted to POS at the discretion of the Regional Center board. The primary roles of the Regional Centers are to identify eligible people, determine with the clients what supports are appropriate to the client's needs and aspirations, finding and purchasing those supports typically through vendors, and monitoring the quality of the support provided by vendors.

A few things all honest participants in this system can probably agree on:
1. All the activities Regional Centers are charged with are necessary.
2. The quality and effectiveness of Regional Center performance varies greatly between Regional Centers
3. There is probably an efficient formula for how much effort is spent on each Regional Center activity but no-one knows how to find it. Many of the formulas used are defined in statute.
4. Methods and policies employed at Regional Centers are of varying effectiveness, but there is no standard to distinguish success from failure within a frighteningly broad range. Also failure to budget accurately is the only failure likely to trigger oversight.

A few opinions I'll add with honest intent and questionable intellect and little expectation of conscensus:
1. Reasonable people may disagree as to whether all the activities Regional Centers are charged with should be done at Regional Centers, There may be economies of scale combining some activities between RCs but there are probably synergies (for example between quality assurance and service coordinators) that add value in keeping these activities together. Any proposal to change the functional makeup of Regional Centers should receive a whole lot of scrutiny.
2. The quality and effectiveness of Regional Centers' performance hardly varies at all over time. In my experience, badly run RCs stay bad and well-run ones tend to stay good. If I were going to propose Regional Center reform, I think this would be the most compelling fact.
3. The problem with any RC operations reform is that we don't track outcomes in our system. There is no basis, therefore, to improve staffing formulas. Smaller caseload ratios in service coordination could, for example, theoretically save money by reducing the purchases of chronically unsuccessful support or providing for more effective matching. It's highly likely that the right formula is different for rural RCs than it is for urban ones.
4. In my opinion, much of the proposals we've seen for reforming Regional Center operations reflect a lot of frustration with individual Regional Centers, how their responsibilities are discharged and the overwhelming difficulty (within the margin of error from impossibility) of changing Regional Center behavior.
5. I may be crazy, but the idea self-perpetuating boards overseeing public entitlements seems kind of goofy and pretty suspect.

Based on all of the above, I would be reluctant to support changes in what Regional Centers are meant to do or staffed for. Nonetheless, the frustration of clients, their families and vendors working with many Regional Centers is awfully well justified. Even the best Regional Centers are better at contract enforcement than determining program quality and its rare that they do well at informing families of options. Laws are regularly flouted at the worst regional centers. The entities charged with Regional Center oversight rarely act aggressively and appear fairly powerless.

The fact that many Regional Centers function badly doesn't call into question the value of those functions they do badly. On the contrary, the frustration throngs of us share at chronic failures proves the value of those activities. The best correction will be to amend the uncorrectability of these agencies. History found feudalism unsustainable. That duly elected officials have restored it for people with disabilities would make a cute irony if it weren't so wrong.

Tuesday, August 10, 2004

Accountability and Reform

We all like accountability, in principle and for other people. Someone reading past entrys in this blog to this point might think I'm trying to suggest that accountability is the most important reform for this system, more than funding, more than restructuring. That's about right.

The value of accountability, or the cost of its absence, is at the heart of the system's inefficiency in my opinion. I'll explain:
The system was designed to be more efficient than existing systems because of it's flexibility. Clients would receive those services that help, and not receive assistance that doesn't. Clients and their service coordinators would select those supports best suited to the client's challenges and aspirations or try to devise something better. Local communities, through the Regional Centers would guide the evolution of the services available to fit with local conditions. All of which works perfectly as long as there's a sound basis for the choices made.

The system, as designed is efficient because it allows enough flexibility to move people into less restrictive environments which are generally far less costly and because the individualization can prevent the expense of unnecessary, unhelpful or inappropriate support.

The lack of evaluation (which isn't getting better) and oversight (which still has a long way to go) has two effects which probably inflate the cost of the system without helping the clients:

First- There's a general lack of reliable information about what works and doesn't, which programs are effective and how some agencies might make a good match for a given client. As a consequence, it is nearly impossible for a client or family to select wisely or proactively. There's insufficient basis for a service coordinator to have confidence in a recommendation. Although nearly all agencies strive for excellence, only our own brochures indicate to us whether changes we make are going in the right or wrong direction.

Second- Theories aren't tested. Especially at the policy level (Regional Centers or the State,) there's no means to discern between policies that bring positive change and those that damage the ability of the community to support individuals with developmental disabilities. Several Regional Centers and DDS are run by layers of smart, mission-centered managers with smart, critical boards. Several are run by charlatans a long way down with complacent or self-serving boards. Regardless, the best intended ideas of smart people can be wrong as can the conspiracies of scoundrels. With no witness to the outcomes, either through their measurement or independent consideration, policies may serve the opposite of their intent for years without reversal. In this system the failure to recognize failed policies costs our clients and our state in the currencies of wellbeing and general fund dollars.

So, this blog will go on to discuss other proposed reforms. Now it has been said, my central conviction is that the best first reform for the sake of people with disabilities and the state budget would be the creation of real systemwide accountability.

This is why my office is in a brick building. Harder to blow down.

Tuesday, August 03, 2004

Oversight and Accountability

"For where two or three are gathered together in my name, there am I in the midst of them." Matthew 18:20

When you're omnipotent and omniscient, your presence among those gathered in your name is a grace. When you're disabled and policies affecting your life are debated, your presence among those gathered in your name is self-defense. The importance of organizing both locally and statewide is to insure that when two or three policy-makers gather in our name, we are there in the midst of them.

The flexibility of this system makes tracking changes and policies and the effects of both challenging. Policy is made outside the capitol that effects people with disabilities as well as the cost-effectiveness of the entire system. Regional Centers make policy as do county governments. These actions take place, typically with little community input or oversight. As a consequence, many policy choices which affect the success of the system are not questioned.

The importance of CDCAN (see post from June 22) is the success of the group and it's predecessors in gathering people with disabilities into hearings at which the laws governing our system are enacted. There's no doubting the success of this strategy in protecting our system. Local and statewide oversight by people with disabilities was intended for this system. At every regional center board meeting, at every DDS hearing, at every agency meeting and at every county commission hearing, the stakeholders should be in the middle.