Wednesday, December 30, 2009

Looking forward to 2010

Well, heck. The new year will bring new cuts. We all have known that for a while and none of us have any excuse for not being ready for them. I just updated my resumé, for example. I do hope people understand that the next round of cuts proposed might eliminate entire programs and, perhaps, state departments. But for my optimistic year's end post, I'd like to suggest criteria for guessing whether DDS thought through the cuts it is about to propose:

If the cuts proposed have been (tragic but) thoughtful:
  1. Rates will compress toward the low end, not fall by a fixed percentage.
  2. In explaining the cuts, resistance by large lobbying organizations won't be mentioned.
  3. Those will be least affected who are most urgently in need.
  4. The package will contain not only clear descriptions of what regional centers are to do differently, but enforcement mechanisms for reining in inventive interpretations or, at least, an expressed and manifest willingness to publicly side with other stakeholders some of the time.
  5. Andy Pereira will need to think a short while before ranting.
  6. Some non-residential agencies may actually close.
  7. Contrary to the "furthest from the client" meme, the scope of support will narrow more than oversight fades.
  8. Many members of the cost-cutting stakeholder group will complain that they weren't listened to and mean it this time.
  9. The interdisciplinary team (IDT) approach, Individual Program Plan (IPP) primacy and fair hearing rights will be strengthened.
  10. The limits on the IDT and IPP will be clarified, in terms of requiring a clinical and practical rationale for support.
To expand on my thinking (apart from my comment about Andy- you just gotta know Andy,) ideology will not produce a budget solution nor a human solution. To get both, consideration must be applied to efficiently shrinking the system, maximizing cuts realized (rather than scored) and minimizing disruption acknowledged (rather than ignored.)

The first challenge is that we have spent years in denial that any change to the system is necessary and one result of that is that the map of the system isn't much more detailed than it was 9 years ago when I got here (and when the map showed "Here be dragons" across the state.) So there is no real possibility that the changes to be proposed will be wise or wholesome.

That said, some common sense can be applied. It is clearly better to retain a decreased number of low-cost support agents than to continue trying to keep all the state's executive directors employed. This is why a downward compression of rates is wiser than a fixed reduction and why it is better to restore the clinical and practical requirements to the scope of a client's service than to list categories of service to be discontinued.

Because we can't describe our current reality (without lying, exaggerating or generalizing beyond the scope of surrealism,) it is important to retain whatever intelligence the system does feature. This is why both quality assurance and the ID teams remain an important feature. There's also some hope to be had that if the system shrinks more than its smarter features, the system itself can grow a little less mystical in process and product.

Likewise, for the system to grow smarter it is absolutely mandatory that regional centers grow less glib, for clients to have clear understanding of new limitations and for some agencies to close. But the most important factor is that stewardship of this system and its resources for the benefit of the people served has to improve for the remnants to matter. Which is why such proposals as an x% rate cut across the board or the evacuation of regional centers will prove a lack of good thinking by the administration.

Of course, this budget is bad enough that we just have all non-residential care proposed for elimination. In which case, dangit.

Tuesday, November 17, 2009

The (Draft) Ten Guiding Principles for the ICBM

At the request of Anonymous, here is the draft I received as the "ten guiding principles for the Individual Choice Bugeting Model Process." (ICBM) I am typing this all in so I expect Anonymous gratitude.

  • Reduces overall state General Fund costs.
  • Increases fairness, equity, and transparency in the allocation of resources.
  • Accounts for geographical cost differences.
  • To the extent possible, relies on existing state data systems and assessment processes.
  • Accommodates individuals with exceptional or unique care needs and their associated purchase-of-service costs.
  • Easy and efficient to administer for consumers, families and regional center personnel.
  • Does not jeopardize individual's health, safety and/or well-being.
  • Does not impose any unfunded mandates on participants, providers or regional centers.
  • Promotes individuals' ability to achieve and maintain living arrangements and work in the least restrictive settings.
  • To the extent possible, can be implemented within existing resources.

A few things I would note. First, just to cushion the sarcasm to follow, I'll just say that I don't disagree with anything listed and I don't mean to criticize the author(s) in particular.

With that said, I think it is less important what the principles are than that there are ten. This is clearly a document of good intentions, more than a design plan. It is also worth noting that with a maybe exception for the third principle, these are all principles designed into the traditional system as well. On the one hand, you can consider ICBM a useful attempt to try again. On the other hand, there is nothing in these principles to provide for anyone's optimism.

The last thing I'd point out is that nothing here refers to using unvendored supports, decreasing the involvement of the regional center or either providing relief from or adding to the current, expensive and unimpressively accountable regulatory system. So the pessimists I call my brothers and sisters and inanimate or ungendered kin can rightly justify a jaundiced expectation. If ICBM does constitute some sort of constructive reform, that feature will have been added later.

A couple of bonus thoughts at no additional charge: One is that the "unfunded mandates" line is interesting given that Counties and IHSS workers are running around buying fingerprint scans willy-nilly and typically at the expense of the provider. I wonder if this line exists in order to specifically lay to rest fears along those lines or whether the author intends it as comforting boilerplate.

Also, the fact that this is a draft of principles and was presented as current in November should maybe suggest to the providers of suspended services to consider other lines of work. If this represents the extent of the work, and it may not, that doesn't promise much in the way of quick development or expeditious deployment.


I recently received a note that DDS did not produce the document quoted above and cited below. This might be good news, as we can hope that the actual development process is further along than it seemed and may also be less obvious. The bad news is that most of what I have written in the two posts now seems frivolous and mean. Well, sort of bad and not at all news, but I do repent of the error.

Wednesday, November 11, 2009

ICBM outgoing

Last week, I received a copy of the draft of 10 guiding principles for the new Individual Choice Budget Model. A few things I'd note. The first is that after several months there is a draft version of 10 guiding principles for the new Individual Choice Budget Model. That right there is discouraging. The second is that the 10 principles look so thoroughly rhetorical. Protect safety, ensure choice, save the state money. Good ideas, all, and I offer this blog as a pretty good proxy for what five years of work along these lines will probably look like.

The rub is you can't really root against them because there are clients and vendors being held hostage until the ICBM is certified by the Director of DDS to have been implemented and to be saving the state money. My modest proposal, submit this blog as the complete implementation of the model and certify that you're saving money by canceling the development.

Tuesday, October 06, 2009

A fair hearing for fair hearings

So, there seem to be vendors in LA County who know that I recently made the executive director of a local regional center angry with a needlessly hostile description of regional center habits vis-a-vis the termination or reduction of services without the prescribed ID team meeting or notification of fair hearing rights. Regarding the degree I exaggerated (I might have said service coordinators never follow the regulations in this situation,) I feel comfortable that I was within the statistical margin of error. Regarding the degree to which my tone was needlessly hostile amid a very strained effort to pull the community together in the best interest of all, I do repent (and did apologize.)

But, while running your mouth foolishly is a terrible pedagogical technique, I mights use the event to talk about the difference between how I, as a vendor, view the fair hearing (and aid pending) laws, which I believe is sharply different from the way regional center personnel hear vendors talk about those laws. Consider this my effort to follow the aforementioned executive director's lead and deepen the partnership between two segments of the community that often don't collaborate or communicate well in good times and have particular need of each other now.

In my experience, by far the commonest way that our services are terminated or reduced begins with a phone call from the service coordinator to the vendor agency. Friends who run agencies throughout the state assure me this is their experience, as well. The client is often left out of the process entirely, even though state be provided a team meeting in which they are to be the leader. At that meeting, if the client does not agree to service termination or reduction of reduction of services both state and federal (for Medical waiver enrollees) law require that they are to be provided notice of their right to appeal, their right to support for the appeal, and their right to continue their service as currently provided until the appeal is resolved, if they choose to appeal. I won't say again that this protocol is never followed, but I will say again that this protocol is rarely followed unless a vendor insists that it be followed.

However, the law is clear, plain and theoretically binding. When someone calls the office or an ¡Arriba! supervisor to say that "I am cutting" or "I have to cut" or "these new regulations require that I cut" services, we are all trained to remind them of the regulations which apply to that process. The result is almost always an ID team meeting at which the SC explains to the client the reason for the cut, the staff make sure the client understands what is being done and, most importantly, the client has the opportunity to review what is proposed, consider what the price will be and then the ID team can work together to look for solutions if the transition will create important problems.

The value of the hearing rights is not necessarily in the hearings themselves. More often, the value comes from the ID team everybody felt too busy to sit in on until it was required. ¡Arriba! staff are forbidden from encouraging clients to appeal, unless the client first states that they are uncomfortable with the change. I have been director of this agency for nine years and to the best of my recollection, our clients have had informal hearings maybe three or four times and formal hearings zero times. But many times, clients have had productive ID team meetings as a consequence of the threat of an appeal. While we are all looking to thoughtfully make the best solutions for our budget problems, I would argue that the ID team meetings will be crucial.

As long as the best way to get a thoughtful, collaborative meeting remains the threat of an appeal, vendors should remain vigilant about insisting on those rights. (Plus, they are, you know, rights.) While a regional center employee might receive reminders of the regulations as antagonistic, from this vendor's perspective, we insist on them for collaborative purposes.

Thursday, September 03, 2009

Praise Where It's Due

I have been critical on this site (and most places I've bothered to write or speak) of our legislators' lack of curiosity regarding the outcomes of the program they fund with taxpayer money. So I have to give credit to Assemblymember Hector Delatorre of Southgate. The commentary below and decision to audit the system represent a surprisingly thoughtful first step on a long road toward capable legislative oversight of DDS.

Given that a letter from vendors was cited as a reason for the audit, you can imagine why whistle-blower protection plays such a big role in Delatorre's presentation. That wouldn't have been on my list of first topics, particularly because client confidentiality and the vagaries of client choice make proof of retaliation unlikely even upon granting whistleblower immunity. Whistleblower protection could be a useful cog in some future accountability machine, and any of you who read this blog frequently know how I feel about accountability. Still, only a vendor could think this was the best beginning.

But I have to say, I was impressed by Delatorre's grasp of the subtler point that regional centers function as much as government agencies as they do as non-profit public benefit organizations. That isn't as obvious as it is true and the Assemblyman brings up points in the video below I had certainly never thought of. This issue has a stomach-turning potential to turn out in strange ways if explored in depth, and many of those ways might be sort of sinister. But I'm going to guess that restructuring the system away from regional centers or absorbing them into the apparatus of the state is far far beyond anything the legislature will be ready to handle soon.

I'll confess I'm a little concerned about the feedback the audit will receive. If the audit committee were auditing the vendor community, quite a bit of the feedback from other stakeholders would surely be scathing and some of that unfair. In this case, the same is likely to be true. People like to come forward with a complaint. Sycophancy is also a risk.

At some later point, I might write something about opportunities and risks that loom behind this survey. But, for now, kudos to the assemblymember for taking an interest in our system.

Monday, August 31, 2009

Mr. Manners and five budget cutting taboos

The following is my first ever attempt to opine on good manners but, clearly, we need a new post up and this is what I got.

Brother Doug's Behavioral Tip for DDS:
When Regional Centers are wrong, be strong. In the past, Regional Centers have acted variously with regard to the need to cut costs. Some have been consultative and careful. Others have behaved as stupidly, precipitously and imperiously as a rabid whippet in a fox' den. On those occasions, DDS (as well as Disability Rights California) have been worse than useful so far as I can tell. I can only assume DDS allows regional centers their heads (wooden and otherwise) based on the idea that nobody comes willingly to cuts and other stakeholders will be fractious and unwilling in any case. I think this is a mistake.

When Westside Regional Center came out with their (dismal) expenditure plan years ago, many of the elements were clearly in violation of trailer bill language. Nonetheless, DDS was publicly supportive and despite that support, the community was fractious and rebellious and it took months for any POS behavior to change. As a counter-example, San Gabriel/Pomona Regional Center got upstream of some cuts by making them collaboratively in a forward looking way. Of course there are some yet to make, but I would wager that by working with the community, some spending reductions are already realizing savings and have done so since May without much rebellion and, so far as I am aware, any needless loss of life and welfare (as I was sorry to witness when FDLRC made it's expenditure plan without resistance.) Any strength DDS shows in preventing regional centers from too much expedition is likely to be rewarded with client welfare and more savings.

Dom Douglas's Tips for Regional Centers: Get in the habit of respecting the rights of clients and what wisdom there is in vendors and family members. As above (and in the post below) the imperious, expeditious management style is likely to be expensive, inefficient and produce needlessly sorrowful outcomes. I know most if not all of you think that all clients and vendors do with cuts is complain and resist. As a vendor and a family member, I would that we're only bumptious when laws that don't exist are given as reasons for things we hope to avoid. Generally, the community understands why there are cuts but we want them implemented as thoughtfully as possible. Most regional centers have never tested experimentally what would happen if a collaborative, person-centered approach were taken. Most other stakeholders have an evidence basis to doubt that pushy regional centers will do much well or right. Now is a good time to learn collaboration together.

Cousin Doug's epistle to other regional center vendors: To the degree that Regional Centers will work with us, the clients will listen to us and the DDS will defend, act also in good faith. It is not our place to provoke clients and antagonize service coordinators who have reached a mutually successful agreement. Those clients who need our help defending needed supports continue to have the right to a fair hearing. We will make much better advocates for those clients that need defending if we don't try to create clients who want defending. It will be harder for our detractors to accuse us of refusing to give up units of service if we show discretion and good taste. This year will stink financially for direct care providers and their bosses more than anyone else in the system, but the system doesn't owe us a living, either.

Ole' Doug's advice to clients and their families: Understand that everyone supporting you is under stress. This doesn't require apology, gratitude or certainly not the stifling of grievances (we need grievances expressed now more than ever.) But remember that however foolish, selfish, useless, youthful, greedy, controlling or impenetrable the professionals around you might be by nature, there are forces pressing us to be worse. If our behavior were personal, it would be much better.

To my friends in the chamber of commerce: Ironically, the most expensive ways we do things tend to be the least integrative of people into the community. The best ways we can implement our budget cuts for fiscal purposes and/or to preserve the value of the system will be for you all to see more of us. Take this opportunity to make new friends, employees and customers.

Tuesday, August 04, 2009

Baron-centered services

When we talk about person-centered services, and most of us speak about such services reverently, we assume that the most efficient and most morally appropriate support for people with disabilities would form from the will of the end user, be shaped by those closest to the end user and that each degree of separation from the end user would decrease influence significantly. I don't challenge that assumption which I find works both philosophically and mathematically.

I have written before here how frustrating it can be the degree to which advice, technical assistance, rule-making and program formation follow a feudal system in which the principality of DDS is invoked by the baronies of the regional centers to direct the viscounts and baronets of the various vendored agencies. This is the least efficient, most morally suspicious method of standardizing services, particularly when the message seems to be "Here is how to provide person-centered services."

A feudal system requires the consent of the governed as much as a Democracy does. It bears mentioning that one reason the community-based system revolves around such centralized control has been that the vendors are so cagey, political and reluctant to insist that knowledge flow both ways or even offer some when asked. Clients and their families could provide more guidance too, probably.

And yet, in the current funding environment, I find it noteworthy that in our collective panic, the trend seems to be toward a more feudal system, particularly where information sharing is concerned. The ELARC board retreat, rather than a conversation, was allocated nearly entirely to congratulating the regional center (something it deserves- in many ways ELARC has been a model of administrative competence) and the promotion of some person-centered tools they developed. The participants, vendors, clients and family members were asked their input only in the final 15 minutes and in response to the question "What can we do to promote use of these instruments."

So let it be said here that the purpose of this meeting was to promote person-centered process offers only irony and evidence that many who promote individualized support don't understand what they say they are promoting.

If current events require a new level of partnership and a higher degree of efficiency, there will be much more time spent in which vendors, families and clients instruct regional centers. It takes effort to make a smart system and it takes thought. The distributed wisdom of community-based system ought to be our best instrument for making opportunity ought of current challenges. To that end, the certainty of regional center personnel and the recalcitrance of direct care users and providers are the most obvious obstacles.

Sidenote: I don't suspect that regional center personnel or vendors are intentionally complicit in the centralized course of decision-making in this system. I just think that findings have followed the funding for so long that long-time participants in the system, a group in which I'll soon have to admit membership, don't even realize how arrogantly or submissively they are behaving.

Tuesday, July 14, 2009

Serving Stanley for Free

In the comments for the previous post, Stanley asked:
"Thanks for providing specific provider details...hate to push one so willing to provide such information...butbut wondering how do rates compare with actual cost of providing quality rates paid by RC cover all cost of providing quality support...are all IPP needs/goals covered by rates.

Questions arise based on process used to determine cost of providing support for my, agency gave RC cost to provide support...RC either approved or denied these cost...I do not recall any mention of what rate would apply...there was no discussion of an agency who could provide same support for less...did such an agency does one quantify/equate lower rate and program quality.

And among many things I have not seen is a list of state-set rates...there seems to be a disconnect between rates, cuts and cost...also

How do cuts effect Lanterman, Though DDS wrote that it will maintain the entitlement of the Lanterman Act, it simultaneously wrote that it would mitigate the expenses associated with the growth in population?"
Here are some thoughts, I invite readers to add their own:

1) I am absolutely certain that rates and quality are not perfectly or even well correlated. There are a lot of things that cost money to do badly and are free if you do them well. Just as a quick example, with individualized services, there is always a tension between management's idea of how those services should be provided and the end user's. There is always a fiduciary concern that the client's money be spent appropriately pitted against the client's interest in having their money spent according to their wishes in a timely fashion. An agency can spend a lot of money imposing the management's interest while many clients provide their own vision for free. This is just a theory, but I have long suspected that leaner individualized supports are probably much more person-centered supports.

To agencies like ¡Arriba!, fairly lean individualized providers, the most important benefit from better funding is staff retention. But if management is injudicious or unwise in who gets retained, as I confess to having been on a few occasions, then quality doesn't benefit. Good funding can allow management to be too comfortable trusting staff and allow people who could more productively do something else stick around longer. So better rates can improve or erode quality, depending on the willingness of managers, staff and clients to make difficult decisions before making payroll becomes a maybe thing.

A few cautions, though: A lean, quality-focused, person-centered agency most likely will see quality go up and down as rates do. I guess my answer to that part of the question is that the impact of budget cuts on accessibility is more obvious than the impact on quality. Another caution is I know even less than DDS and the regional centers what the factors of quality in a congregate support are. It may be that as services become more intentionally programmatic, standardized and institutional that funding per unit of service has a simpler and more positive correlation with quality.

2) The connection between rates and the IPP is obvious if you are talking about SLS or the total Regional Center POS budget. Otherwise, the IPP is purchased by buying units of service that may not be through the same vendor code or agency. At ¡Arriba!, for example, we can support every part of a client's IPP at our new, lower rate but the cost goes up because we have to add hours of service for each goal we work on with a client. I understand that for SLS clients and SDS clients the "rate" is a composite of costs pursuing different parts of the IPP so it would surprise me if an SLS provider could say yes in answer to your question. I can, though, provided I am given enough authorized hours to juggle it all.

Obviously, if the POS budget is capped this year (but exists) then some IPPs will have to get less ambitious. That might even be a good thing if we could trust people to prioritize wisely and thoughtfully. If anyone reads this and trust that IPPs will diminish wisely and thoughtfully, please let me know in the comments. I'd sure like to hear it.

As to your comment about the disconnect you perceive between rates, costs and cuts- I can only agree. It's madness. A herd of cows would design a more rational system. A pack of wolves would design a more honest one. A cabal of cannibals would design a more defensible one.

**Update** Through the good offices of a good friend, Stanley, here is the list of rates and rate-setting mechanisms:

Tuesday, July 07, 2009

Dreaming with the Governor

While we're waiting for work to be done by the legislature, and since I haven't posted here in a month, I have some thoughts about one plank in the Governor's proposed cuts to DDS. One of the elements of the cost-cutting plan calls for Regional Centers to refer clients to the lowest cost provider of the desired service who is able to meet the requirements of the client. My agency seems to be the current low cost provider of individualized supports serving the SGPRC catchment area and, perhaps, the ELARC catchment area as well.

In a way, this is a better bad policy than most, at least from the provider perspective, particularly where agencies with state-set rates are concerned. The biggest budgetary risk from the rate cut implemented February 1 will be that vendors with already low rates close and are replaced with agencies whose rates remain higher than those charged by the low-cost providers before the cut. In fact, when the rate cut went through, ¡Arriba! was the second lowest-cost provider and remained so until our better closed in April. The risk is that unit costs rise or, at least, the overall affect becomes uncertain.

One smart way to avoid that trouble would be to cap rates rather than lower them proportionally. In that case, high-cost providers would be forced to charge less and if they failed to restructure their costs, they would be more likely replaced by lower-cost vendors.

But the proposal makes some sense, too. Under it, lower cost providers are to be strengthened after the proportional cuts through higher volume. This should help preserve the lower-cost providers. Setting aside for the moment my usual bitterness that the system should be so vendor-centered, at least the budgetary intent has a better shot with this proposal implemented.

Except it probably won't be implemented. I have very little hope that this agency will see more referrals. Regional centers are already incented to and expected to use the low-cost provider able to meet the clients' needs. When the previous low-cost provider closed, how many of their former clients were referred to us for service? Exactly. Even in the middle of a financial crisis that forced the regional center to cut hours, the lowest-cost alternative wasn't used.

So worry not, my friends, about this particular piece of trailer bill. Should it pass, your friends and loved ones will not be herded into low-cost programs but will continue to enjoy the higher-cost services of whatever quality they now receive. Hopefully, the cut was scored conservatively.

Thursday, June 04, 2009

The meaning of Marty

As many more people than are ever likely to read this blog now know, Marty Omoto today announced the suspension of his advocacy work through the California Disability Community Action Network.  As everyone I'm aware reads this blog knows, Marty and I are both friends and colleagues and I admit to both a bias and an interest in his welfare.  So, like Mark Antony over the body of Caesar, I want to publicly share some thoughts about the systemic importance of Marty's work while maintaining the friendship privately.  Friends, Californians, countrymen, I come to contextualize Marty, not to praise him.

Going back to the days when he was with UCP, Marty is best known for his reports and townhall meetings.  Leaving aside other accomplishments, Marty's work has revolutionized advocacy in the narrowest sense of that word, preparing the people whose welfare is most affected by public policy with information and involving them in their own struggle.  

This is not the way things were done when I entered this system in 2000.  During the Service Delivery Reform effort, my introduction to this system, California's DD policy and Sacramento, stakeholders represented peers who were strangers.  A good person elected by a dozen or a hundred others to represent People First spoke for 200,000 strangers.  Someone selected by the State Council on Developmental disabilities spoke for the same 200,000 strangers.  A few associations sent lobbyists or representatives (of which one was Marty.)  These associations might have 100 or 200 members each or ten or twelve, and they would speak for their 8,000 peers, the overwhelming majority of whom were strangers.  ARCA would speak for their members and the 8000 providers and the 200,000 clients.  SEIU spoke for workers in the field, of whom, maybe, a few thousand were voting members and 100,000 were not consulted in any useful form or fashion.

Marty shared inside late-breaking information at all hours, to anyone interested.  Somewhere around 50,000 people are now kept up to date and provided a platform for input through Marty's efforts.  Is it possible that any stakeholder group ever gathered by DDS included the will of 500 people who had been substantively consulted or that 1000 people ever learned what had been discussed by any other channel?  

In an open vote in a public place, the proposition that our work ought to be person-centered would receive something near consensus.  In that same forum, we would pass a resolution for the dignity of every person with disabilities and their right to informed consent.  Any group of us with strangers watching supports the inclusion of people with disabilities into the whole tapestry of our society.  "Nothing about us without us" would be acclaimed at convention up to the rafters and down the street, born on the shoulders of confident advocates and electric wheelchairs.

In our system, there is always room for disagreeing with one another, always room for arguing with one another, and outside of the present emergency, even some room for pillaging, cheating and insulting each other.  But if we understand those principals we claim to uphold, there has to be room and support for the distributed, democratic and collective advocacy that wasn't here before Marty put it here and isn't likely to remain if he departs.

Thursday, May 21, 2009

Save your self(-determination)

On this blog, we have discussed SDS (self-determination or self-directed services.)  For examples, you can click here (and please forgive the self-referential first result.)  I have tended to argue stridently for self-determination in concept and ambivalently for self-determination services as proposed and grouchily about SDS' roll-out.  Now SDS seems dead after an unfriendly end-of-life. But the basic concept still seems relevant, particularly with the traditional DDS system wheezing and scowling.

So, a first question would be what was the basic concept?  If you read the languishing proposal to the federal government, you don't know.  But I would argue that the basic premise was that the individual level is the best one for identifying and addressing the needs of an individual.  
When you look at what SDS offered, there are obvious efficiencies available under a person-centered service regime which can save the state money and improve benefits.  Now that the SDS movement is on the shoals and it's cargo poisoning seals, we have an opportunity to consider whether what was important in SDS remains viable and worth salvaging from the wreck.

Self-identification of needs and solutions remains, in theory, the official law of the land and the funniest joke in the villages.   There exist more than one way of putting the I back in IPP/IFSP.  Certainly, the preference for providing supports by availability rather than appropriateness allows a great deal of waste in our system, of state funds and client energy.  This ought to remain a focus in bad financial times more than in good ones.

Administrative cost will continue, I'd think, to be under pressure.  Instead, this is what advocates seem to defend most passionately.  Clients who are able to protect themselves don't need to be paid to do so.  Clients who are able to advocate for themselves don't need to be paid to do so.  Clients who can judge among available options for their own goals don't need to be paid to do so.  So why hasn't the devolution of the purchase and oversight power of regional centers and vendored executives come under attack with the community budget, for those clients able to take up the same task?  Even the development of SDS empowered regional centers, progressively, to apply themselves to tasks capable individuals will do for free.  

Throughout our current budget fandango, deregulation continues to not come up as a means of reducing fiscal pressure.  It ought to be remembered that beside stifling innovation, regulations always have a fiscal cost as well.  A correct system will balance the cost of regulation and supervision against the not unreasonable fear of liberated vendors.  SDS offers a terrific vehicle for testing a more person-centered regime as a cost-effective means of oversight, but even without SDS, some rebalancing is called for.

Unvendored services still offer more cost-effective resources for many currently vendored efforts.  As long as the only way some ¡Arriba! clients can reliably carry out normal activities is by ¡Arriba! employee chaperones, we will continue to provide that assistance at our new, low, low rate.  But there are a lot of trips for which a neighbor with a Camaro and twenty bucks for gas is an almost perfect substitute at half the cost.  SDS was a useful model for testing the safety and availability of unvendored providers of unskilled services.  Even without SDS, policy-makers ought to be broadening system resources. Unvendored services can often be more integrative and inclusive than vendored ones.

Without a formal SDS proposal, some of the the composite policies still offer relief to a stressed system.  The development of those policies, in turn, can increase the level of self-determination in our system.  SDS may now be decomposing and might have started to decompose premortem, but before we bury the remains, it's worth seeing if there aren't some nutritious bones left in the carcass.  If we aren't that hungry yet, we are likely to be soon.

Friday, May 08, 2009

Impertinent data

At the Senate subcommittee meeting yesterday, I was reading through the agenda which mentioned DDS's annual report which was described as "pertinent data" about the people served by the system.  Let's use that as an excuse to talk about what data DDS doesn't provide (or gather.)  Service outcomes would sure be useful, particularly in a shrinking budget.  Which Independent- and Supported Living agencies are most or least likely to help someone move out from a residential facility, and which are most likely to see their clients return to licensed lives? Which employment models and agencies are most likely to see their clients move upward in income and downward in support need?  Which residential facilities serve happy clients and which are essentially traps?  Which transportation agencies have the best record of picking up on-time and dropping off uninjured?  Do some agencies see more abuse than others?

Other pertinent data would be pertinent data.  Do some regional centers provide more information on options and alternatives without being asked?  Do some regional centers see their clients live more fully or require less support over time?  Are there regional center policies that might correlate with outcomes?  Which regional center will be the first to notify a client of their appeal rights as required? 

This would all be pertinent data.  This information would help our system learn, evolve and do better work with less waste.  We would be better off if we had no idea how many Californian 15-year-olds have diagnoses of autism and some notion of what works for those that do.

Monday, May 04, 2009

The people and their anointed

California's political system is a funny creature.  Our politics tangle in the radical democracy of the ballot initiatives then get caged by the radical republicanism of legislators who choose their constituents rather than the other way around.  I never feel our government truly represents the people except when I compare the results of the two law-making processes.  When I insult our legislators, it is principally over their carefully districted intransigence against common sense, voting aye on every expenditure without a thought for value and nay on every tax without a care for cost.  And yet, we seem about to vote down the proposition 1x tax increases and how often does a bond measure fail?  The two systems really are parallel. 

Somehow, the one heroic effort of the legislature- to redact representation from their duties of office- has also failed.

Better government ahead?

The good and great have reminded me that I haven't posted here in a while.  I started to, now and then, but obviously, I'm delinquent earning my pay and reputation as a blogger.  I have no coherent or clever ideas to post about, so now is a perfect time to remedy the situation.

Generally speaking, I have been an enthusiastic critic of California's legislature and a temperate admirer of the administration.  One thought substitute I can offer is this: We may reasonably hope that California's government improves as a result of the budget crisis.  The legislature might improve because fools and cowards wait to be forced before acting, so the impossibility of California's budget may be enough to move a super-majority, if not a consensus in the statehouse.  Someone should spray paint legislators shoes on the capitol carpet to verify, but our representatives may start to move any day now.

The administration might improve also because of reduced friction.  For three terms now, DDS has sought to reduce the growth of its spending.  Good ideas and bad ideas have come to naught (the resistance obviously being to ideas.)  In our current predicament,  the reform instinct ought to be nearly as common outside the Bateson building as it is within. 

There are reasons a reforming government may not be a good thing.  Some of the ideas that have come out of DDS for reform have spanned the range from simplistic to stupid, the statewide POS standards being an example of the latter category, and "discounted" rates an example of the former.  But some, such as self-determination/direction and performance accounting have been inspired unaccomplishments.  If the administration can focus on smart reform, to the purpose of more efficiently serving people with disabilities and the legislature can learn to say yes to good ideas and no to advocates as needed, then the California's burgeoning poverty may yet profit the state.

Wednesday, March 18, 2009

And a note on trust and reform

Here is something in the way of reform: Who do we trust?

If a reform requires regional center discretion, such as the frequent proposal to require maximum cost efficiency from a vendor or allowing negotiated payments, most of the community won't trust the reform because we don't as a rule trust regional centers.  We don't trust regional centers because as a rule, they aren't trustworthy.  They aren't trustworthy because, as a rule, when someone at a regional center does something unwise, whimsical or badly, nothing unpleasant will happen to them.  This tends to be true for individual service coordinators, executives, boards and middle managers.  The community but for ARCA won't support reforms that empower the regional center to do anything because we all know well that regional centers are too empowered already.

If a reform empowers vendored agencies, we won't support it either.  Take for instance, the example of proposals to have vendors rather than regional centers perform the service coordination function.  The community won't support that reform to empower private vendors because the community doesn't trust us and the community doesn't trust us because we have not been reliably trustworthy.  We are not reliably trustworthy because, in general, nothing bad ever happens to agencies for poor performance.  Nothing bad happens to agencies for poor performance because nothing bad happens to regional centers for poor performance.

There are a lot of reasons that self-determined services (SDS) make sense, but I suspect one reason SDS offers the only recent example of reform (stalled as it is) must be that it doesn't empower anyone who has any experience with power to be proven untrustworthy.  Not long hence, support brokers and financial management services must take their places as proxies for the politically untouchable clients as stereotypical reprobates.  Soon, we will not trust them because they will not have been trustworthy because nothing will happen to the bad ones because nothing bad will happen to the people meant to oversee them.

Reliable accountability remains the reform needed before any other can be expected to go forward. 

Wednesday, March 11, 2009

A note on DDS work groups.

Today during the CDCAN town hall teleconference, DDS Director Terri Delgadillo mentioned the working groups she has convened to look at structural reform. Such working groups are typically composed primarily of association representatives and an aberration or two.  Recognizing that these work groups are a step toward transparency and community input, a few questions ought to be asked.

How representative are the work groups?
How transparent are the meetings?
Do the work groups advance a reform agenda?

The first question is easy.  The work groups are not representative in any important way.  They do tend to be diverse ideologically in the sense that whatever CRA is calling itself now always defends congregate facilities and whatever Protection and Advocacy is calling itself now, had its staff been trained in the practical arts rather than law, would likely chloroform and kidnap every client that entered such a place.  But there's a problem of selection bias in calling the work groups ideologically diverse.  As long as CRA' and PAI' are at the table, congregation v integration seems like a more important issue than it does almost anywhere else.  So, what passes for diversity tends be a divergence of limited viewpoints rather a collective voice.  The work groups seem not to be meaningfully integrated into or representative of the greater community of people interested in the development or reform of our system.  

I suspect if you could inebriate the architects of the work groups (and you generally can,) they would tell you that the real selection is based on getting buy-in rather than input.  The first composition probably begins with the list of groups with the means to scuttle or inconvenience legislation, continues with the natural opponents of the first group, and ends with Connie L. This is politically smart, and as long as the goal is pacific politics, the process makes sense.  But if the time for reform has come at last, workgroups made up of well known "stakeholders" with rigid "positions" will get in the way.

Friday, February 20, 2009

Measuring caps on the Mohs scale.

There are several notorious topics to pick up after my sabbatical from this blog. My favorite format on this blog has been the debate format, so let's start with a discussion of the hard cap on spending which I believe will be on the ballot in May. (Part of the compromise made with Republicans for a fifth of their votes.)  If voters approve the proposition (I'm guessing,) the spending side of the state budget will be limited to current spending plus a growth factor, likely to equal population growth plus inflation.

There's no question a hard cap causes realistic concerns for the future of this system and, more importantly, the people the system serves. But the notion not only attacks the principle of a community digging in to support the needs of their neighbors, it also defends the principle of good government. As with previous debate posts (here and here,) I'll post five arguments for and against a proposition and invite commenters to give their own opinions.

The proposition:  A hard cap on state spending may benefit people supported by California's developmental disability system.

1. With the size of government set in the constitution, the focus may move from polarizing and tiresome demagoguery to governance.  The debate I listened to from the Senate Gallery on Wednesday and read in the press was a competition between a philosophy that taxes are the root of all evil and one that government spending is the sole source of earthly virtue.  If the voters set the proper size of government, legislators can turn to subtler and more constructive discussions of priorities and process.  Of course, we'll probably need a whole different set of legislators to grasp the concept.
2.  Under a spending cap regime, voters will have to better interrogate their own values.  As dismal as our legislators have been, their most meritorious action has been to claim to represent their constituents.  In proposition after proposition and election after election, spending whether for water, punishment or people with problems seems to get our rubber stamp.  If the hard cap requires that long imprisonments and prosperous prison guards must be weighed against help for people born challenged, it is entirely possible that we discover ourselves to be a little more Tamino with our neighbors and a little less Night Queen.  A society that chose help for a struggling neighbor over vengeance upon an erring one might be easier for the disabled to integrate into.
3.  A leaner system might produce better outcomes.  Another way our State has failed to choose is between the well-intentioned control-freak and the good-hearted failure.  Regulations build up in our system for good reasons but without any cost-benefit analysis.  Meanwhile, the system does not discriminate between (or identify) functionaries and agencies that are highly productive and those that kindly serve badly.  There are often many people who have to say yes before an individual can be served, or their services can change.  Heaven alone knows how many people are struggling needlessly due to ineffective support.  Hell has the accounting on needless regulatory costs. If this system has to struggle with choices, some of the energy and resources we lose might well be doing mild harm or weak good while stronger support is available
4.  A trade-off between growth and predictability has value.  The cycle has quickened from annual to pretty near monthly in which promises are made, budget crises confessed,promises revoked, outrage erupts and the promises get restated but only partially and decreasingly kept.  It's hard to imagine who benefits from such chaos.  A system in which per-person funding declined slowly and predictably might be better than such a volatile one, even setting aside that the funding outcome might not be worse.  A learning system could probably improve efficiency and keep pace with the declines in capacity if those declines were predictable.  Morever, it is unrealistic to think government can continue to grow sustainably  as a share of society.  
5.  We have more important battles to fight.  This is almost corollary to the point above, but I remember a conversation with the mother of a 40-year-old with autism when her son was about 32. My friend said, at a protest of budget cuts, that we haven't even started the right war yet.  The important struggle has always been making the system work better for those it serves.  At least since I got here in 2000, the urgent one has been funding.  Steven Covey says that what is important but not urgent makes the best use of time.

1.  Changes in the frequency and severity of developmental disabilities do not track the population and or correlate with inflation.  Duh.  The increasing frequency of autism, for example, had nothing to do with the factors which will ultimately determine the total size of the state budget.  Once a hard cap is enshrined in the constitution, the state will lose flexibility to address important changes.
2.  See #2 of the pro arguments.  We might also discover that as a people we really prefer to persecute our neighbors than to meet them.  In fact, I kinda do.
3.  Competition for state funds favors the many and the well-funded.  Even after clients, families, support staff and people of conscience are totaled up, those who fear crime, want wider roads and/or use marijuana outnumber us.  Teachers, prison guards and ne'er-do-wells are more organized and wealthier.  In an uncapped budget, there are two ways we can grow: by winning an argument with other beneficiaries or one with tax protestors.  Under a hard cap, we can only grow at the expense of another beneficiary.  What's more, other beneficiaries will see us the same way.
4.  There is no reason to think our system will get smarter as it gets leaner.  The record so far: We cut less costly and more integrated service modalities more aggressively than more expensive and segregated ones.  We cut low-cost providers proportionally with more expensive providers of the same service.  Most new regulations are written for the purpose of containing cost and avoiding risk, not to make services more efficient or integrative.  The best and smartest advocates our system has had in the legislature haven't succeeded in making positive reforms.  Nothing has been accomplished in my time here to make the market mechanisms in the system work to allow useful accountability, transparency or information to clients or family members.  A cheap dumb system is unlikely to function as well as a prosperous dumb system.
5.  Are self-directed services rolled out yet?  Right.  SDS in many ways represents a miniature of  the best we could hope for from a capped state government and three gubernatorial terms have not brought it to statewide reality.  Unpromising.

OK, y'all's turn.

Wednesday, January 14, 2009

A note about position papers

I read the ARCA position paper today, and will just call it a proxy for all the others out there in order to save time. When the state has an unsustainable budget and the legislature has shown itself unable to think or act and you release a paper announcing your opposition to most of the cuts, the intended audience is fellow stakeholders not government.  Kind of like the guy who raises his hand in class because he wants the attention of a classmate. Very thorough, although they seem to have left out their position on cuts to DDS headquarters. Can anyone tell me what else is missing?