Tuesday, January 22, 2008

Brand New Same Old?

A good friend wrote to me with a comment on my previous post below.  

The email read, in part, "ok-- i agree with your points- but trust me - sds will end up being mostly same old same old.

This is worth discussing. I invite my friends who lurk here, cross post to list servers, and/or read out of a sense of friendly obligation to discuss this in the comments section. Comments can be left anonymously but on the off-chance a conversation actually develops here, I ask for this: If you comment anonymously, please use a pseudonym or unique signature so participants can respond to your comment with some form of address.

Five reasons to think self-directed services, SDS, will be a new, more valuable and more efficient model of service delivery:

1.  Program design belongs to the person or family served.  A client-centered design is not guaranteed but it should be the most natural result.  In the traditional model, the wisdom, insight, bias and preference of the service provider and service coordinator are the most likely guidance.
2.  To the extent that accountability and oversight are transferred away from the regional center to the people served, inefficiencies in defining, assessing and assuring quality are significantly reduced.  These inefficiencies in the traditional model widely deplete fiscal resources, human resources and efficacy.
3.  Layers of overhead can be eliminated.  Vendorization of service providers, reporting requirements, worker's compensation, mandatory reporting, employer liability, general liability are all provider costs that can be eliminated or reduced under SDS, especially where the client does not use a co-employer agency.  Insurance for SDS clients is a brilliant investment for SDS dollars where staffing is involved.
4.  To the extent that decision-making is located in the client's home, rather than in the broker and/or regional center, the iterative reviews of client choices that inhibit both creativity and dispatch can be reduced.  For those of you who were reading during the series on Value Stream Management which began here, this represents an efficiency improvement referred to as making the value stream flow.
5.  As neighbors and system civilians replace agencies in the provision of some supports, natural supports in the community can be constructed and strengthened.

Five reasons to suspect that SDS will turn into the same old corruption we're saddled with now:

1.  The development of the regulations followed the same process of speculative problem-solving that many feel inhibits creativity and thins the robustness of supported living.  I have argued here that regulations for the system have been overwritten, undercomplied with and often ambiguous, detracting from the very virtues of efficiency, market-driven discipline and individualism that characterized the original intent and intelligence of the Lanterman Act. These regulations are well-intended, thoughtful and smart but it is probably the nature of regulation writers to see regulations in too positive a light and, what's more, California regulators have to harmonize with the habits of federal lawgivers.  There is no reason, based on available drafts of the upcoming regulations to think SDS won't be over-regulated, stiffening the flexibility we look to for a better model.
2.  While brilliant people have made sincere and thoughtful cases for the exclusion of people being served in congregate settings and allowances have been made to overcome that criterion, the concern remains that the most costly, least person-centered and most confining parts of the system have been protected from the reforms involved.  This also means those who can benefit the most from SDS will be excluded.  This creates two risks: The first, that salutary results will be diminished, reducing enthusiasm and advocacy the program will need to survive or thrive.  The second, that as the more individualized and person-centered supports grow leaner, the already expansive portion of advocacy and consultation offered by bulkier, less responsive agencies continues to grow.
3.  Scoundrels are scoundrels wherever they gather.  The regulations leave a lot of room for regional center input and control.  There's no certainty that service brokers will function as envisioned.  The same bad habits that attenuate the virtues of the current system can easily thrive in the new system.
4.  While some regional centers, including the five pilot sites and San Gabriel/Pomona have shown commendable enthusiasm for the new program, it will not be difficult for regional centers leery of SDS at the management level to undermine, redefine and/or disincline the engagement of the program.
5.  The spontaneous occurrence of idiocy remains a distinct possibility.  By idiocy, I offer this example.  Stupidity that limits the flexibility of service models intended to provide responsive, person-centered care and justified by incomprehensible paeans to quality, person-centeredness and "the principles of the New Day conference" not only occur but find limited resistance and meet little reason.  If Westside and Orange County regional centers can do it to ILS, they can repeat with SDS.  Two or three years out, look for regional centers to propose converting SDS into a formal congregate steeplechase and be met with a resounding "um."

Your turn.  Discuss.

Wednesday, January 16, 2008

A return to Heurism and/or Wereism

This is the one hundredth post on this website, a cause for celebration no doubt and maybe kindness or neutrality.  To think without cynicism is to hear the beating of angels' wings through a bird-splashed windshield, but I have had some thoughts recently about how the "Support broker" position in self-directed services might develop differently than it is conceived so far.

As presented, the position is largely designed to provide for two functions, that of a person-centered plan-writing guru and secondly as a clearinghouse for referrals to appropriate resources available for SDS client/managers to fulfill their plans.  Without disparaging either function, I wonder if there aren't roles of greater value into which the service broker role might grow, much as ILS agencies have changed wherever permitted from the role initially conceived to a more valuable one unforeseen but unprevented by regulations.

While person-centered planning as a brand-name set of operations can be a wonderful contribution to the service and support people receive, some of that value may be diluted by the self-directed aspect of self-directed services.  What's more, as much as I and ¡Arriba! have been and continue to be boosters of Essential Lifestyle Planning and person-centered thinking, we have been boosters with a sneaking suspicion that the basic ideas are more important to advocates on average than to the people the thinking is meant to be centered on, paradoxically.  It is almost certain also that "person-centeredness" has a much wider dominion as an amorphous catchphrase translating, approximately, to the English "Holy" or "Pious" than it does as a practice.

The clearinghouse function will, for many SDS clients be sufficient and magical.  If a client's purpose is to recreate at lower cost and with greater control the traditional one:one services they've received, and that client lives in an environment with a high density of people with disabilities, then their purpose is a grand one. For these SDS clients, an advisor who makes a business out of knowing who is providing what supports at what costs and how their clients seem to enjoy the service can be very valuable.  In more rural or less-served communities, in languages spoken by very few, and to people whose purpose with SDS is to more creative than, say, replacing supported employment with a look-alike SDS equivalent, it is not clear what breadth of knowledge would be necessary to make a service broker a useful expert, or how they could possible charge enough for such expertise.

So, with the wisdom of a service broker whose caseload is expected to double this month from one to two clients, I will speculate out loud that a primary function of the service broker will be as a management consultant to SDS clients.   It has been such a long fight to acknowledge that people with disabilities, themselves, have the best ideas for what they value and need, that we might have grown reluctant to acknowledge that other capacities, such as designing and managing programs that work are learned skills.  There is no reason to assume that any given SDS client will not be a brilliant manager and reliable planner, but there is also no reason to expect her neighbor to be.  

If you look from agency to agency- ok we've established this doesn't happen- if someone would look from agency to agency with an eye to quality and efficiency there might be a wide variation.  For SDS clients who have to depend largely on themselves for their success, that kind of variation endangers the success of the SDS program and the wellbeing of clients who don't get it right away.  Regional center staff, generally, will not be able to provide advice on program management any more reliably than clients will intuit that knowledge instinctively.  However, a service broker with experience in program management can provide real value toward greater success and security of individual SDS programs.  For some subset of SDS clients, management consulting will be the most valuable function of a service broker.

What does this theory require of us now?  Probably nothing.  While the SDS guidelines will probably over-regulate who can be a service-broker, the basic function of management consultant is not forbidden to service brokers.  It is always worth remembering with new things that unexpected results might be salutary.  I think the only policy suggestion I have to offer for now, is that when the time comes to review and improve whatever regulations are about to be promulgated, that some thought be given to a more nuanced method of preventing conflicts of interest if to do so will improve the quality of service brokers.