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 programs...do 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 daughter...eg/ie, 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 exist...how 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 entitlements...ie/eg, 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:

33 comments:

stanley said...

THANKS.
much to ponder...hope there will be comments that provide a better understanding of how the system works...mainly how funds are distributed...

stanley seigler

Raggedy-assed Andy said...

I've been out of the loop ... pushing boulders up hills and thinking of new manifestos on ending the promises we could never keep ...

Every neighbor a savior. Every town an Emerald City.

Below is the opening from an opinion, or findings rather, from the almost always reliable LAO in 2005. Link to the whole shebang at the end of this excerpt.


Towards A More Systematic Rate-Setting Model

The Department of Developmental Services (DDS) and its system of regional centers provide a wide array of services and supports for the developmentally disabled. Our analysis indicates that the way that DDS and the RCs set rates for the vendors who provide these services also varies widely—and as a whole lacks a rational and consistent approach. In this analysis, we review how rates are set for these services and offer an improved and systematic approach to rate-setting that could ensure that the state does not overpay for services.


Follow the link after I stop jabbering. Rates, and rate setting are addressed in this report half-way down the page ... it seems pretty much dead on to me...though it doesn't begin to describe the extent of the disparity ... a cosmic absurdity beyond the capacities of earnest analyists. (I'll save some favorite examples for another time). Still, this is a very good primer for Stanley, and Livingston, and anyone interested in the impotency of truth ...

Oh, I suppose, with or witout any power,truth's still a better companion than most, I suppose.

http://www.lao.ca.gov/analysis_2005/Health_ss/hss_09_4300_anl05.htm


Hope to be in loop again someday ... I miss dressing up for the internet ... maybe I'll wear my new manifesto next time (tease, tease, Stanton)

A. Pereira
Mainstream, Inc...
"... doing god's work since 1994, or whenever he stopped coming into the office."

stanley said...

[raggedy andy say] It [LAO 2005 findings] seems pretty much dead on to me...though it doesn't begin to describe the extent of the disparity...a cosmic absurdity beyond the capacities of earnest analyists. (I'll save some favorite examples for another time). Still, this is a very good primer for Stanley, and Livingston, and anyone interested in the impotency of truth...[end ra say]

hate to agree with one who pleasures in teasing old men...however it does seem dead on as long as box thinking applies...and concepts might be appropriate when moving out of the box to insure most cost effective means of administrating a program such as microboards...much to digest...more later.

For now thanks for the link...guess LAO gave up after 2005...any feed back from DDS or anyone...

stanley seigler

Doug said...

Stanley, of course.

Raggedy Andy, it doesn't take genii to see that the rate-setting is not rational, but reading their recommendations, LAO is still in shallow water.

Stanley, I presume- Andy is being friendly. You can tell when he's being unfriendly because he sends someone else.

Andrew said...

I have just found out the hard way that your most expansive, generous posters are now restricted to bits of twittering thought and comments. 4,096 characters! I've just cleared my throat by then!

I hope you like trilogies!

PART 1

Douglas sez: Stanley, I presume- Andy is being friendly. You can tell when he's being unfriendly because he sends someone else.

Yeah...well..."someone else" is not the same guy he once was.

Calls in sick all the time ... bitches incessantly...out how he's always hungry (alleges he’s a victim of “Size-ism”, and has a “right” to a burger and fries once in a while). He whines about how itchy and uncomfortable a hooded black cloak is in the summer...how hazardous a scythe can be in a crowd—claims they get to use sickles in Europe. Swears there’s no way to distinguish Stanley’s house from his neighbors (hey, Einstein! ...try the one with the vacant homes on all sides?)

The latest? Supposedly, it’s too far to drive but too close to fly...wants to subcontract! (as if Paul could drop that kind of weight in a hundred years!)

Gonna have to provide my own unfriendliness, I’m afraid. Damn SEIU!...turned a quiet, reliable guy into a monster...totally different attitude after AB 1682.

I must agree with Doug's earlier points about small, leaner agencies (whatever it was, I remember agreeing). But I'm not completely in agreement about increased referrals bringing some parity with it ... in SLS, at least. I stopped taking referrals after our Agnews commitment was met a few years ago. Every referral accepted requires anywhere from 3 to 7 new staff positions. Without any kind of profit margin, every additional hour of service brings only additional cost and risk, and an hour closer to the precipice.

At this time last year, our management was three or four positions below 'barely adequate'. We've since cut it by another 1.5 positions to absorb February's rate cut and spare direct service staff.

We need growth in ILS and in our day program (both have decent rates) to keep SLS viable. But without managers, growth becomes hard to come by, and hard to handle if, and when, it comes.

We're down to 1/4 positions for HR and bookkeeping and if I haven't quite picked up the all the slack, I've at least got my foot on it ...or near it. I don't enjoy poorly managing two of our three programs while demonstrating an impressive inadequacy as CEO, CFO, COO, and serving as both the Department Director and Department for QA, R&D, Marketing, Program Development, Customer and Community Relations, Resource Development, Procurement, Facilities Maintenance and Secret Santa …. but anyone with somewhat stable employment at this time, with which they can support them self and their family, has no cause to complain.

Two of our three services are adequately funded … while one is severely underfunded by 40% - 60%. With years to massage cost statements and refine their pleas for help and doomsday proclamations, I think there are many providers, fat and happy. Brand new providers, taking any one of a number of temporary rates the state has set, can (with enough referrals) do far better than we can. In fact, a new SLS provider starting within the past year, or next week, will receive a higher rate of reimbursement than our agency of 15 years and top flight reputation. I don’t want to come off as a cry-baby … but that’s just screwed up.

Andrew said...

PART 2

You know what they say,you pay for experience. You just pay more for less, in our world. You get used to it, but it's a little harder to accept the inequalities between certain categories or essential services and non essential services. Shelter? or sheltered workshop?

So maybe this is where the "cap" Doug suggested comes in. Or,why not apply rate cuts based on how robust one's rate has become? If you're at the top tier of the service category, maybe you eat a 10 or 15% cut, and if you're at the bottom, maybe an increase is in order. Afterall, cost statements rewarded those that lost money (or showed a loss, I should say).

Obviously if better rates were given in exchange for better services, this wouldn't make any sense ... except to our dear friend, Stanley the Cranky Pinko.

I can accept a 10% cut to some of our services ... but our SLS can't manage 2%. I am hoping the times may at last provoke us to follow the money. Where's it going and for what ... isn't that the first thing you do when your income drops?

Andrew said...

PART 3 - RETURN OF THE RATES

Who knows what this tangled mess provokes? Real reform? It's not as easy as it sounds. So, I won’t hold my breath …. just my nose as I offer the following unpleasant calculations.

(The SLS rate used for these swift kicks to my head are based on our overall average hourly rate, which combines and averages the three service rates we receive, Admin, sleep, and personal assistance. The rates used for the other services are based on the temporary rates established by DDS)

--- To earn $1000 in reimbursement, our SLS we must provide 60 hours of service.

For other services to earn reimbursements totaling $1000?

Sheltered Workshop --- 11 hours --- (@ 15:1 client/staff ratio)
Infant Development Program ---12.5 hours --- (1:1…. same as SLS)
Day Program –DTAC --- 20.5 hours (8:1)
Day Program –Beh. Mngt. ---- 27.5 hours ----(3:1)
ILS ----31.5 hours ----(1:1)
Supported Employment ----32.5 hours----
(1:1)

…. and so it goes.

Actual rates of the other services listed are often higher. Even “In Home Respite,” the redheaded stepchild of the service system, clocks out after 55 hours. When did they get a bump?

Also, keep in mind that workshops aren’t bound by ratio requirements of all other services… they can go above 15:1 if they want or need to. That's the critical flexibility you need when you're cut. Of course, you'll hear about cost of doing business and the high overhead needed to maintain a faux factory. When they have finished explaining that there is so much you don't see, ask for the number they listed as "overhead" on their last United Way application.

I'm not against workshops--I've seen a great spirit of brotherhood and community and kindness at times in workshops...times when staff have left for lunch, usually. But I think, when it comes down to having a place to live that doesn't require several others to live with you, or having a place to stuff envelopes a few hours a day,one's home comes first.

-- Another way to see how great the gap can be between services.is to think of starting a small, 1 staff service.

Suppose you open a workshop with 1 staff and 15 clients and operate M – F, 9 am -3 pm, At the end of the first year, you would have received $133,000 in reimbursements.

If you’re smart like me, you shun the idea of a workshop and open a small SLS agency with 1 staff working 9 to 3, Monday thru Friday. At the end of your first year you can honestly report a $25,000 income to the people at the food stamp office (remember, it’s bad form to run to the next spot in line if you see your staff approaching the office at the same moment as you!)

In using time to measure system absurdity and disparity, you can consider the average annual increase in our SLS personal assistance rate over the past 15 years. If today we were to receive an hourly reimbursement equal to a brand new Infant Development Service, we would have had to start our service 764 years ….. before the Black Death swept through Europe in 1348 AD.

Yes, somewhere around the late of the 6th century...very tough epoch to launch a start-up, from what I've heard. The Church convened its best and brightest in Lyon at the time, to debate the question, “Are women human?” A time of great uncertainty, no doubt, but fortunately for those who prefer to remain "in species" for their matrimonial considerations, the votes came in at 32 to 31 … for the yays.

Andy

Next time? Measuring rate increases in Geologic time.

stanley said...

[Andy say] I hope you like trilogies! [end as]

Stop teasing an old man...just help one understand what rates were used to determine agnews people in the community:

state officials say this form of housing is less expensive...it costs $288,000 a year on average for a resident at a state-run institution in California; in the community, it will eventually cost about $40,000 less a year($248,000).http://groups.yahoo.com/group/DDRIGHTS/message/3883

the agnews rates; andy’s PART 3 - RETURN OF THE RATES; and the current traitor bill language lead to the abandonment of all hope LAO or anyone will make any sense of DDS funding rates...in my or Gods lifetime...

how about DDS/RCs just going out, to qualified agencies, for competitative bids to provide IDT determined needs detailed in the IPP...perhaps this is what actually happens now...if so why all the confusion re rates...

stanley seigler

Doug said...

Sorry for the delay, friends. I had to carb up before answering Andreas.

Andy, I had no idea about the 4,096 character limit. I'm kind of shocked to know there's any limit and we hadn't already crossed it.

Part 1: You're right and one of the many madnesses of the rate-setting system is that the process results in new agencies automatically being better funded than older agencies. From what I understand, the current tweak reduces this somewhat but still. The incentive, as with so much of life, is to be young.

Part 2: That's the right meta-change, I think. Unfortunately it preserves the perfect discorrelation between rates and results, but at least it would put the most pressure on those best able to withstand the pressure. Note, they did not do this, but maybe in October, when the legislature again has to face the fact that there's a deficit and no way to borrow it away.

Part 3: I am very skeptical of the math in this section. When Julie and I compared rates and what was covered by them, with you at the table on your third or fourth drink, it turned out that all in, our ILS and her SLS received almost identical funding per hour of service. The difference was explained because ILS does not get an administrative fee and SLS generally doesn't have to pay people to travel between clients as ILS does.

Stanley, I don't know but I think that's what happens and the Agnews closure clients are free to change agencies. I feel cautious about criticizing that program, though. Many advocates, and I think you were one, complained vociferously about the money wasted at Agnews and this program was the one needed politically to close Agnews. Second, because taking away funding from that program kind of undermines the ones community advocates make. It's hard to say "We should have robust funding for people with developmental disabilities" and simultaneously complain when a few get just that. Third, they are as much us as anyone. Lastly, there's no reason to think that if that money weren't budgeted for Agnews people, it wouldn't instead have gone to either deficit reduction or prison guards.

Andrew said...

PROLOGUE

Doug, thank you for your skepticism, but before I get into the muck of my math, I want to say that I think the 4,096 character limit is a recent restriction from the gods of E Blog. I’m sure I’ve exceeded it almost every time I’ve posted … Merely posting a punch line, or a patented pithy put-down of Stan the Baptist. Once, I quoted a sentence Paul had posted—indirectly, which I did hoping to retrofit P.’s syntax in the process. Don’t ask me why, in the interest of time and ease, I just didn’t drop a hundred hits of acid instead! I thought, by the end, that it was the End … and whatever part of the brain formulates language …had melted!… and was seeping from my ears. I tried to call for help, but I couldn’t conjure up the word!

Anyway, that one sentence alone had to be over 5 grand. If you haven’t noticed anything, they probably allow the host unlimited characters (the rich get richer) … the rest of us?... well, we certainly wouldn’t want to clutter up the internet, would we?

I’m pretty darn confident in the math that I used (more so than in the bar on the napkin …and if I was 3 to 4 drinks into the evening, I can understand why the numbers might be off …. that pencil doesn’t get sharpened until at least a six pack has disappeared. …who does math sober?) I’m even more confident in the sense that my scenarios accurately reflect the disparity and absurdity of the rate system, if not precisely perfect numbers.

If I can satisfy you with my math, Doug (speaking on a purely literal and intellectual level) will you, at last, concede me my poverty? Or, I’ll take a bow down and your worship, for the work we’ve done to improve our services over the past several years, with nothing more than the force of will and the crumbs and crusts of moldering reimbursements? No need to make a big production out of it …. five to ten seconds of your worship will be plenty (Equal, in my book, to at least a half-hour of full-throated veneration by most all of my other colleagues. I've converted Stanley so many times, I could have had him mowing my lawn forever, if I only could afford a lawn). Should bending and scraping pose any risk to your back or your beliefs, I’ll come up with a safe and suitable accommodation.

(Back on message) It is, particularly because of the ubiquitous “Administrative Rate” defense that I recently worked out the actual combined numbers for our service. I knew our admin rate had no basis and little effect. It was established with guesses in 1994 when our “Communications” line item consisted of two pagers and a two-line phone service. I finally ran the numbers so I could be the only one in the room to know what our Admin rates actually did for us. I’m not referring to you, Doug, when I say I knew I needed this stake to drive through the heart of the beast, to kill it, once and for all, before any real discussion could begin.

Andrew said...

EPILOGUE

The term “Administrative Rate” is always the first, the last, and the only sound I hear back in the call and response cadence of “bitching and dismissing” whenever I have sung my part in the Rates Opera. Lately it’s become an interruption, coming before I can complete my first sentence of spite and lamentation … My spite cut off! This is my gift! My spite is all I really have to leave to this world … if I can’t give my greatest gift to those who need it most, I see no point in going on.

Okay …. enough of that ... self-indulgent self-amusement (mustn’t clutter the internet!). Let’s get down to it … down to the knuckles and numbers of a real supported living service. I not sure, but I doubt if the bar napkin took into account sleep rates or the actual hours Julie’s agency, or ours, provides. There are some common misunderstandings, I think, especially among our funders,but even with other SLS providers, that seem assumed and understood as the God’s truth from factories …. drawn from a social worker’s notions of profit and industry … of economies of scale and mass production. “The more hours of service you provide, the more money you’ll make” … and, in seeming contradiction … “The more hours provided, the lower the cost per hour.” Like ball point pens, right? Nope, like surgery. (In our area, unlike most, the service coordinator is on point and is our first, of potentially six negotiating partners, in the process of securing each person’s SLS services)

In actuality, the greater the number of service hours, the higher our costs, risks and complexities. And, unlike the truth from factories, more hours mean a lower combined hourly rate. This is due, in part, to spreading the Admin rate over a greater number of hours, thinning its negligible effects further, over every hour of service. Big hours usually mean continuous supervision through the night. This ready presence is, of course, paid for, hour for hour, through the authorization of a seperate “Sleep Rate” ($11.29 hr). Think of dimes dancing in your dreams for eight to twelve hours each night, while you’re being paid at the minimum wage. (And, if I have to hear, one more time, the fake envy of a dithering, dickering funder …. “Gee, I’d sure like to get paid to sleep” …. I can not be accountable for the knee-jerk sarcasm that will follow … "But, dear Broderick, you already do. The difference is that those other people, the staff, have to do it at night and away from the office!” gasp! ) It can or cannot be a good gig … or both, sometimes.

When I add up the total monthly payment received for all of our “regular hours” ($16.64 hr.) plus all of our “sleep hours” ($11.29 hr.) and all of our monthly “admin rates” ($888.37 mo. per person) I come up with our total monthly payment for service. When divided by the total number of hours of service we provide each month, our payment rate per hour, based on total reimbursement is:

Gimme a damn drum roll!

$17.39 hr. ….. Ta dah! ….doh!

We have a lot of 24/7 folks and, as I mentioned, it’s thought, that this must be where the profit is made. "Just look at how much is spent!" The cost of labor is the cost of labor, and you can’t fudge on ratios in SLS. If you don't make anything on an hour of service, you don't make anything more on a million hours. But you'll be a lot safer doing only one hour.

The highest number of monthly hours we receive for one person is for someone who was once, I think, considered a “One Percenter” (the 1% of people in the system presenting the greatest challenges to community and developmental center services).

On the way to the end of the road, this person was sent up and down the state, starting and being booted from eleven residential placements in ten years. At the end of the road, of course, was a developmental center.

Andrew said...

ANALOGUE

This person receives two to one staffing 80% of the time, most of it at night (1 staff asleep [sometimes], and 1 awake) which produces a lot of hours and cost but barely a penny of profit. It breaks down like this ….

823 regular rate hours per month at $16.64 hr. . . . . = 13,695 mo.

375 sleep rate hours per month at $11.59 hr. . . . . = 4,384 mo.

….. (1198 total hrs. of service per month) ….

1 monthly Administrative Rate . . . . . . . . . . . . . . . . . = 888.37 mo.

Total reimbursement per month . . . . . . . . . . . . . . . . = 18,967 mo.

18,967 mo. divided by 1198 service hours per month equals an hourly reimbursement rate of $15.83 hr.


By contrast, the person we serve with the lowest number of service hours per month is authorized for only 94 regular hours (at 16.64 hr.) per month equaling a monthly reimbursement of $1,564. Adding the admin rate of 888.37 to this, gives us $2,452.37 per month, divided by 94 hrs., equals an hourly service rate of $26.09 hr. (This is our highest combined rate, while the previous rate of 15.83 is our third lowest--$14.98 is first)

(I must say, that if these numbers have conveyed an impression of the people whose service hours I am using for examples, the image can’t be anything but wrong. The numbers barely describe ghosts. But maybe it’s still unfair to simply leave it at that, with no more than a caution. I owe it to my example to try to dispel any lingering myth.

The first person presented, with the greatest number of hours, was indeed incredibly challenging … considerably more so than the Lesch-Nyhan boys, of later on. From my complete incompetence at the start of our service, followed by eight years of our frequent and consistent failures—though progressively muted in their effect—we finally achieved a kind of break through when this person’s trust in us—perhaps realizing it was impossible to get kicked out of our service—converged with a sudden and deeper understanding of the person. From that point on, seven years ago, there has been steady and clear improvement in all aspects of this amazing and remarkable person’s life. I learned a lot about myself, about the role of service, about the proper place of disability in one’s life, about trust as the lynch pin, and about the deeper complexity and commonalities of human beings. This person, not their numbers, has profoundly effected nearly all functions of our agency. If the monthly cost appears high—even though the payment disapates long before it gets anywhere near our bank---the cost of service is still less than it was years ago, when the developmental center was providing 1:1 supervision, unless no one was looking.

Also, what was learned through this process about Prader-Willi Syndrome, we have been able to replicate with others, and it should be of great and lasting value to many people with PWS and their families, as soon as I can find a little time to publicize it and share it. If looked at as a successful R & D project, the cost of this service will be seen as insignificant)


Sorry …I think if I’m going to describe people with developmental disabilities in any way, I need to make some effort at doing a decent job of it… and a lack of time, or inconvenience, or the stamina of blog readers, is an unacceptable excuse. They are neither simple, shallow nor stupid. Until we in the field finally believe that, everything else is pie in the sky.

I admit I can get scared giving or seeing numbers sometimes; knowing what the Ayn Rands of services and state politics can do with numbers that can be plucked out of context, and shown in a flash of sleight of hand. Did you know … almost anybody could read this, if they wanted?

Andrew said...

LINCOLN LOGS


So, D-Pas (or Oug-Over), I will assume, combined rates that amount to $17.39 hr. for a supported living service is not what the napkin bespoke. And if you fire back with proof of my riches, I’ll add into the mix, all the IHSS hours … for which we assume much of the responsibility without a penny of income—now, c’mon …what other business is foolish enough to accept an arrangement like that? All of the joys of employing your fellow man, with none of the revenue! If I can find someone to pick up this piece as a subcontract ... I will expect to see everyone on their knees!

(hmmmmmm... can you spell... PEO?)

We survive, I guess, because we look at management as something we can get by without …. In other words, if you think of direct service staff as representing “food and sustenance” (grubs and brackish water), managers represent “clothing and shelter” (squirrel skins and hollow trees). When the weather starts to change, and it would be nice to have something to put on …. socks and boxers, at least.

But, this too shall pass …. won’t it, Pa?

AP

Boo's Bane said...

“it's now time to be right about something else. You're never going to be a cowboy, unless you ride more than one bronc.”

Andy

I hear ya…

But I have already been on far too many trips to Brokeback mountain with your boy Boo and gang. “I CAN quite DDS”.

But I will gladly read the reportage, prevarications, and tui culpas (just for you andy) as long as nobody turns into a Joker. Asking questions for 10 years with apparently little knowledge to show for it comes close to acknowledging the fact that “some just want to [complain about the world burning].”

I do have other examples..other broncos. But really – do we need to continue to prove gravity?

Andy,
Thanks for the length, effort. On a weekend to boot! But – to be honest I have come to enjoy the “bits of twittering thought and comments” because I do not expect much more than prating and B.S. (not the usual B.S.)

Doug
"Serving Stanley for Free"...apropos title

Andrew said...

Boo Bane confezzez: Thanks for the length, effort. On a weekend to boot! But – to be honest I have come to enjoy the “bits of twittering thought and comments”

What's a weekend?

I'll tell you what a weekend is! It's no better time than to strive to undermine the fortifications of the monolith that crushes the individuality and spirit of developmentally disabled people.

I only pray you do the same.

If that makes me an "advodiva", so be it!

Your easy preference for concise, insightful discourse is your business. It's a free country ... (for you and those like you ... for all, but the powerless)

If, however, you have the impression that I do not possess an edit button, you are sorely mistaken. I have one of significant size and effect, set squarely in the middle of my forehead, and I am pounding on it with vigor, as I type.

I conclude, to leave you slack-jawed and naked, stripped of your final, filthy rags of doubt and denial. Make no move to shield yourself from the cold glare of a clear truth: I can twitter too!

Don't enjoy the rest of your weekend ... grab an adjective, get dressed and get busy undermining!

Andy

Doug said...

Andy, I don't question your math vis-a-vis your own SLS. I'm skeptical of the comparison. That said, I appreciate your taking the time to explain SLS rate-setting. I didn't know the method and this is a better answer to Stanley than I could give.

Boo's Bane, welcome. A friend of Andy's is a friend of mine. Unless you're Paul in which case a self of Paul is a friend of mine, I think. For the record, I have the edit button.

stanley said...

[ap say] Gimme a damn drum roll! $17.39 hr. ….. Ta dah! ….doh!

You got it...especially for the way you spend a weekend: [ap say] I'll tell you what a weekend is! It's no better time than to strive to undermine the fortifications of the monolith that crushes the individuality and spirit of developmentally disabled people.

Many thanks to you and doug for all the free consultation/information…hope more read it and use of the insights to improve the determination of rates…OTOH hope the ayn rands do not use some of the details against you all and the special needs folks...ie;

[ap say] I admit I can get scared giving or seeing numbers sometimes; knowing what the Ayn Rands of services and state politics can do with numbers that can be plucked out of context, and shown in a flash of sleight of hand. Did you know ... almost anybody could read this, if they wanted? [end ap say]

[doug say] I feel cautious about criticizing that program, though. Many advocates, and I think you were one, complained vociferously about the money wasted at Agnews and this program was the one needed politically to close Agnews. [end d-say]

not sure I was one if “was”...didn’t mean to be...I believe the rate given agnews is close to what needed for all requiring 1:1...my problem was how DDS/RCs could justify anything less for those already in the community...ie, recommending cuts to already insuffient funding...


re: FAQ http://www.dds.ca.gov/Rates/ReimbRates.cfm
27. -How does the Department set Supported Living Service (SLS) rates?
A-The Department does not set SLS rates, but, through its regulations, requires that SLS rates be arrived at through negotiations between the regional center and each SLS vendor. Once negotiated, the rate or rates are written into the vendor's SLS contract. Title 17, Section 58661 allows great flexibility in negotiated rate types.

28. -Is there a ceiling placed on SLS rates?
A-No direct ceiling for SLS rates exists; however, the regional center's latitude in providing for the costs of any consumer's supported living arrangement is governed by cost comparisons. Established limits on costs may indirectly affect SLS service rates. (Title 17, Section 58617)

29. -Is there a separate SLS rate for a vendor's administrative costs?
A-Yes. However, often the SLS rate for direct service includes an amount to cover administrative costs. In that event, no separate administrative rate is permitted. (Title 17, Sections 58660, 58662)

[stanley say] how about DDS/RCs just going out, to qualified agencies, for competitative bids to provide IDT determined needs detailed in the IPP...perhaps this is what actually happens now...if so why all the confusion re rates...[end s-say]

repeaing: this seem like what is (or could be) happening vice trying to determine fair rates…and seems like it could apply to all supports/services.

[boo-banes say] But I have already been on far too many trips to Brokeback mountain [end boo say],

not sure how this relates to rates…but perhaps DDS, LAO, whoever can relate brokeback trips to rates and it will help them improve rate setting and contracting services...or was brokeback mt the topic...

stanley seigler

Doug said...

Stanley, whatever someone's ideology, I prefer they have real information to disregard. I like to think that sharing the truth has value, if only shock-value.

As for the folks in the special well-funded homes, yeah, the state rewarded holding out until the bitter end with (I think) extra funding. Whether extra funding makes happier lives is anyone's guess. A good friend who has been a strong advocate for individualized services and SLS within DDS once pointed out to me that if once you have your own home and the ability to survive in it, extra staff just get between you and the community, independence and self control. I dunno but it sounds right. At least, it's consistent with what I've been imagining that a leaner system could be a more responsive one.

As for bidding out, it makes some sense, but I think I can hear the objections already. Some RC folks will probably worry that vendors will bid down to get a client and then, once the client is comfortable use "client choice" as leverage to renegotiate. Given what I know of vendors, the RC folks that worry about that aren't without cause.

Vendors, meanwhile, will object that RCs use the bidding process to get the cheapest rate without regard for the well being of the client. From what I know of RCs, the vendors aren't without cause.

This is why I keep coming back to outcome measurements as crucial to improving the system. I admire many (but not all) of the vendors I know for commitment, and the willingness to sacrifice for the well-being of clients. I admire many (but not all) of the RC folks I know for intelligence, commitment and the willingness to confront vendors on behalf of clients.

All of that said, brilliant people are wasted in agencies that get as little feedback as RCs do. We might even consider the regional centers according to some models of autism in which cognition is unimpaired but the external stimulus is interrupted, leading to the appearance of cognitive disorder.

And well-intentioned, honest people can be wasted
in agencies that face as perverse an incentive structure as vendors do. When it is as clear as it is that quality is unsustainable and mediocrity or worse profitable, without constant vigilance the temptation is to provide mediocre services or worse. In fact, it might be said that natural selection and the current market drives mission out of agencies.

I'm inclined to think if we want the systems to function well, we need to either add useful feedback and incentives, or banish every agency and all RC management/trustees after ten years or so.

stanley said...

[doug say] whatever someone's ideology, I prefer they have real information to disregard. I like to think that sharing the truth has value, if only shock-value.

"Truth is a shining goddess, always veiled, always distant, never wholly approachable, but worthy of all the devotion of which the human spirit is capable" (Bertrand Russell)

truth and rates/funding: the cost of quality programs in the community approach the per capita cost in DCs...unless we can have a system based on positive outcome rewards…dream on...in the meantime the games continue.

BTW the negatives you point out re low bid vendor apply to current and all procedures as well...but of course there is the question, would you want to go to the moon on a space ship built by the low bidder...depends on quality control.

stanley seigler

Andrew said...

Paul, I'll make this brief. The Agnews closure was the first set battle, after a long lull and rearmament in a verylong war. It was deemed crucial by the Army of the Potomac (the abolitionists) to win this battle, for the effect and experience it hoped to bring to future battlefields. And I tend to agree with them.

Every credible and not so credible reason thrown up in defense of keeping DC's alive, over the past 20 years, was addressed, and ultimately overcome by an array of services, service models, permanent housing, increased oversight, staffing and service guarantees established for the closure.

If you look at the specific community services and supports that came online for the residents, you can often see the particular "DC's forever" rationale that spawned it.

As long as there was one good reason left to maintain the peculiar institution, the closure could have been thawrted. What's left now, are only familiar prophecies of misfortune and failure to befall the former inmates in community service settings. It is the last stand of the first battle, and the last hope for a battle cry to rally the troops in the next one.

I really believe it may have been too important to notoverspend, and too necessary to leave familiar fears unallayed. Agnews is a template in many ways, and a learning experience, I hope, in many others.

We serve four folks from the project, and from what I'm told, they're among the most successful in the obvious categories of quality care--the ones you must assure, before the real work begins. I did insist, in our initial proposal and throughout and after our selection, on receiving a higher reimbursement rate than the $17.10 hr (and our same negligible admin rate, Douglas!) we received, at the time, for our other clients.

As we approached the moving date of our first client, our request for service authorization, was denied by a sticky part of the Machine. What followed was several months of "you shall not receive/but we must receive; there isn't any need/indeed there is a need; you know there is a freeze/not for this, and I am done with saying please"

Six months after our orignal move date, our request for $24 hr and $1339 mo. admin was granted. This amounted to $13,847 per month in reimbursement, which included $11.64 hr for sleep rate. When we add another $1572 mo. from IHSS (staff costs we didn't bear) the monthly total reached $15,419 mo. divided by 730 hrs of service per month---a drum roll, Stanton?---our combined overall rate was $21.12 hr.

We weren't providing a new model of service developed to address an obstacle or barrier that stood for decades, so I don't begrudge whatever income was or is given to others, who are learning or doing new service models. We had the same responsibility, though, to do all we could to ensure the success of our clients and the success of the closure.

For us, that simply meant that we recruit and hire and retain staff with strong experience, and pay $14 to $17 hr. and health and dental benefits. Of course, I don't think anyone can say, that this, at least, was a wasteful use of funds.

I think we offer an example of one of the lessons that I hope will be taken from the Agnews experience, and thoughtfully applied to the next plan of battle; the community service providers that will be used, are probably a greater key to success than the model of service provided.

Still, whatever costs were incurred to win the first battle of the new campaign, were likely worth it, I think. Many steadfast, entrenched, dead-body opponents of the closure I knew from the start, now feel their fears and concerns were heard and answered. And many have switched sides, likely to play key parts in disolving the next DC. It may be very premature to judge the price that was paid, and maybe had to be paid, to win this battle. We may not be able to truly measure the cost, or the vaule of what was accomplished at Agnews, until the war's over.

Andy
(21.12 ... call the realtor. Let's go beachfront!)

Doug said...

Very fine quote, Stanley. You're right, the low bidder isn't a good method and yet might be better than the current dart-board method.

Nice prose, AP. I wouldn't worry that promises to Agnews folk will fare any better over time than those made to the rest of us.

stanley said...

Sharing the truth...a BTW range of thoughts on rates and transparency...real information to no information (paranoid)...which is best...

[doug say] whatever someone's ideology, I prefer they have real information to disregard. I like to think that sharing the truth has value, if only shock-value.

[ap say] I admit I can get scared giving or seeing numbers sometimes; knowing what the Ayn Rands of services and state politics can do with numbers that can be plucked out of context, and shown in a flash of sleight of hand. Did you know ... almost anybody could read this, if they wanted? [end ap say]...[doug say] whatever someone's ideology, I prefer they have real information to disregard. I like to think that sharing the truth has value, if only shock-value.

[advodiva say] We are as open & inclusive as possible, encouraging all Autism organizations with many different views & priorities to join. We do not post minutes because we don't want Autism advisaries to know what were doing.

Off topic:

ideology, tho most interpret AR as a free marketeer...could she be interpreted as champion of what works and positive outcomes...regardless of path...ie,

she say: "I am not primarily an advocate of capitalism, but of egoism; and I am not primarily an advocate of egoism, but of reason. If one recognizes the supremacy of reason and applies it consistently, all the rest follows...."

well maybe not that off, off topic...apply reason consistently to rates might improve system...

stanley seigler

Doug said...

Is there a topic to be off of at this point, Stan? For the record, I think end users should only read Rand by choice.

stanley said...

[doug say] Is there a topic to be off of at this point

I kinda thought so...insights to DDS rate setting...your and APs comments have helped me...hope others will read and get something out of it.

stanley

Andrew said...

Stanley dared dream, ... hope others will read and get something out of it."

Stanley, you old pie-in-the-sky optimist, you! "... hoping others will read." Others? Like ...more than one ... other? And who do you believe they might be? Jolly old St. Nick and Bigfoot?

Pay me no mind, dear man, and never lose hold of your dreams. I admit, I am jaded ... hard-bitten and cynical. I don't believe in magic, miracles (on ice, or elsewhere) or tomorrow brings a new day. Tomorrow brings a repetition of the previous 10,000 days. I’ve begun to wonder if Doug is even reading my posts anymore ... Ever since 4096 was seared into my fingertips, I’ve lost the skip in my step ... That leaves you and me ... I’ll read yours if you read mine. (I am trying to get briefer ... it's good for me, I know ... every day, in every way, I am getting briefer and briefer)

Not only do you dream of a day, Candide, when there will be no hate in he hearts of men, and when four, five, maybe up to ten people will read DDSR ...BUT,BUT, you then go all in on a pair of two's and hope our vast sea of readers will "get something out of it," to boot!

But, don’t let me be the albatross hanging from the aspirations you have for both our intimate little group of opinionaters and humanity. Encourage me to try to contribute something more than (too many) words .. allow me an attempt to stir the pot, a bit. With Doug’s permission, a short (I promise!) story and a few simple questions drawn from it, and everything else.

(Two parts are briefer than four)

Andrew said...

One of our local day programs is a branch of a large organization operating several integrated services across the state. It has long been thought of as one of our system’s most progressive agencies and has strongly held to its founding principles of inclusion, integration and normalization, which have been interpreted into policies that fill a thick binder.

The attendees spend all day, every day, community integrating in groups of three, and know they must never to meet up and commingle in a community setting. Accidents happen, though, and when groups collide and find themselves in proximity to each other, staff are expected to make a quick calculation of the percentage of disabled to nondisabled citizens in compromised venue. If their sums indicate a disability ratio of higher 5%, one group must leave the area as soon as possible. (I don’t know what is done when a group enters a small store or a lobby and discovers only one or two [nondisabled] people around. Perhaps they must kill them)

A man I’ve known for years attends this program. He is frequently annoyed by other disabled people, and becomes especially upset when he thinks they may have broken one of the rules laid out in the Agency’s policies. A few months ago he was very upset when a policy of percentages was blatantly disregarded. Due some total fluke of circumstance, three groups found themselves waiting for the same bus. Everyone knew the policy. When two groups are at the same bus stop, the one that arrived last, must wander away, some discreet distance, and allow the first group to board the next bus, after which they can return to the bus stop for the following bus.

On this particular day, it was raining, and the staff, sick of some dumb rule from corporate,” conspired to ignore the policy that assures the program participant’s optimum opportunity for inclusion, and boarded the bus with nine (gasp!) disabled people. The man I know complained loudly to the program’s manager as soon as he next saw her, but I don’t know what, if any, action was brought against the inconsiderate staff. I don’t know if this man understands the reason behind the program’s people percentages ... I hope he doesn’t.

A few weeks following the whistleblower’s expose of “Busgate,” an opportunity arose for staff to take its revenge. The man was discovered, without any kind of excuse, breaking one of the program’s other important rules. He was caught sleeping on the bus, while riding with his group. I hope he understands the reason for this program policy ... because I certainly don’t!

Y con su permiso, Don Pasco, I would like to ask your readership a simple question
...yes or no...

Do we, families and professionals, believe that people with developmental disabilities are a minority group?

(stop me now, before I ask again!)

(too late) Do the developmentally disabled believe that they are a minority group?

If the answer to the first question is, "yes"—Then, has it not been, in essence, the stated aim of our most progressive public policy and services for the past 20 years to erase the group standing and identity of these people?

If the answer to the second question is, "no"—Then, do we bear responsibility for that answer? Have we dismissed and destroyed any shared sense of social and cultural connection; the sense of comfort, ease, acceptance, and understanding that members of other minority groups often seek and experience from each other?

These questions have been on my mind, in some form, for about 20 years. It may be time to stake a claim. (doug, if you are reading this I'll give you five dollars)

I welcome the response of the other...

Andy

paul said...

PART I
“Once negotiated, the rate or rates are written into the vendor's SLS contract. Title 17, Section 58661 allows great flexibility in negotiated rate types.”
Doug

PART II
Title 17 does not exist in a vacuum. Title 17’s enabling statutes, most often within the Lanterman Act, do not exist in a vacuum.

PART III
However – I have noticed that many, if not most, advocates do exist in a vacuum. Some, if not most, by choice.

PART IV
I know the former to be true. If the latter is true I will leave it to the arribails triumvirate to ponder what consequences, if any, may/do result.

Doug said...

That's right, Stanley! That was the topic!

Andy, I'll take the $5 in trade. Something wholesome. Those are great questions and I've pondered them before. I don't like to answer for anyone else but it is true that for every other identity group society seems to have answered the question of integration with "if ya wanna." At the same time, people with disabilities, particularly cognitive ones won't always be able to say what they wanna. But if the definition of "minority" can be said to be "a person or people patronized by the power structure, cooed to and solved." then I have to think the answer to both of your questions is yes.

Paul, feel free to ponder with us. I do think I know this, though- the community-based system is like a perfect free market but with hostages, truncheons and feudal law.

Andrew said...

Douglas writes:" ...people with disabilities, particularly cognitive ones won't always be able to say what they wanna."

True dat. But most of 'em will certainly show you what they want. They only ask, I assume, that we don't require the physically impossible of them ... "...I can't show you what I want, because it's not there any more! You closed it, a-hole. Why weren't you paying attention to me then?"

Because, child, we don't pay very close attentiion when we're listening to something we don't want to hear. I can remember, long before F.C., a number of nonverbal people telling me that day program I had just spent the past two years carefully designing and building for them, was the most ill-concieved, misguided, miserable, meaningless waste of time they had seen since Ward 9, at the Brookebury-Havensville State Developmental Farm HospitalTraining School! ... upstate.

Some wouldn't get off the vans in the morning; others would sprint to the vans in the afternoon. Some kicked holes in the doors; others bit their hands. Some were always absent (if absence was allowed); others fell asleep if no one cared that they did. I didn't know exactly what they wanted, but I knew exactly what they didn't want ... and I've seen it, ever since.

Maybe that's why I find myself glaring more at our profession's 'Religious Left' than it's Religious Right. Maybe because it assumes a higher, moral high ground. Or maybe because it seems to have won. Goliath go old ... retired to a rocking chair on porch. The DC's and giant workshops are fading ....(slowly, but fading!) The theory of integration, of salvation through inclusion, I think clearly has hold of the hearts and minds of at the right thinkers ... the schools; the consutants; the new generation of parents; the conference goers and their speakers. And those who believe in the impossible potential of supported living.

But we aren't the one's living it. We're just the ones giving the orders, far from the front, to the boys in the trenches. Over the wall, boys .... one more charge and you're sure to get through! Let's not fill in the trench while they're gone.

I guess I'm proposing the obvious. . ... Obvious, yet radical in it's respect for the quotidian virtues of comon decency and common sense.

"The Third Way" The way between the twin tyrants ... a strange, new, way to live like everyone else ... without having to be everyone else.

AP

paul said...

“people with disabilities, particularly cognitive ones won't always be able to say what they wanna.”

-doug-



There is of course merit to this statement, and it sits on a love seat with “informed choice”.

The fascinating part is that the “advocates” definition of “properly informed” is when the consumer makes the “right choice”, and we are uncertain of “cognitive” abilities until the consumer makes the “right choice” and then they are sharp as a tack and showing great signs of "independence".

Andy's angst is justifiable.

50 years ago the Can’t People said that people with disabilities Can’t be safe in the community, Can’t make friends, Can’t, and Can’t. S0 – we did the “right” thing and built large institutions to keep Palin’s “most precious resource” safe.

Today, some see themselves as Progressives but they are really just the descendant of “Can’t People”. Today – people with disabilities Can’t congregate, even though every other part of our society is welcome to do so.

People with disabilities Can’t stay home, even though every other part of our society is welcome to do so, they must INTEGRATE.

People with disabilities Can’t be bigots, wake up on the wrong side of the bed, be politically incorrect, sad, or be Republicans, even though every other part of our society is welcome to do so…No No No – People with dis"A"bilites are nothing but "Sugar and spice and all things nice.”

If a person with a disability DAREs to display the foibles of a human being it is certainly there “disability” and they should certainly not be held accountable. Those closest to people with disabilities treat them as non-humans in the name of treating them humanly.

Yesterday - a "disability" was used as a sword that prevented people from living a full life. Today - a "disability" is a shield that prevents people from living a full life.

Many years ago, in our institutions, a ward’s refusal to follow Doctor’s orders was seen as prima facie evidence of incompetency. After all – Dr. knows best.

Today – if a consumer chooses a life choice that is not politically correct it is evidence of not being properly informed or evidence of lacking the cognitive ability to “what they [really] wanna”. After all - Father knows best.

Competency is supposed to be presumed unless shown otherwise. It didn’t work that way 50 years ago, and it doesn’t work that way now. How are “advocates” today ANY different.

Doug said...

I agree, Paul. One of the interesting questions, and maybe this deserves a post to ruminate in, is whether "lives like their non-disabled peers" is meant as normative or should be read as advocating diversity. Most non-disabled people I have know, and all the ones I've been got scolded for their oddnesses but stuck with them.

Meanwhile, you've harried me into a new post.

stanley said...

[doug say] Meanwhile, you've harried me into a new post. [end dp]

Apologies for not making the harried deadline...but want to let AP know another other reads his post.

[Andy say]... other? And who do you believe they might be [end ap]

was really counting on the white rabbit and down the rabbit hole cast... guess I spent too much time as a child looking at radio...I am still listening for the thundering hoof beats of that great horse silver and waiting for that masked man to save lil nell...also have suggested others read dougs blog...eg, a former ARCA pres who seems to listen.

[andy also say] I admit, I am jaded ... hard-bitten and cynical [end ap]

being i have listened to the bs for probably 20 yrs longer than you all...believe my jade and cynicism runs deeper than yours...tho there is progress, eg, nomo snake pits (weel at least only smaller community snake pits)...Lanterman enacted (even if not enforced)...people moved out of agnews...apologies for digressing...to the subject...ap questions:

Q1: does DD community believe it is a minority. A1: yes indeed it is.

Q2: Then, has it not been, in essence, the stated aim of our most progressive public policy and services for the past 20 years to erase the group standing and identity of these people? A2: not sure...in any even, we do bare responsibility...

Not sure I understand the questions...but assume it applies to the example of: One of our local day programs is a branch of a large organization operating several integrated services across the state and its DUMB book of policies...too bad we cant name names...maybe you can share off blog/list.

OTOH if Qs applies to a concern we try to destroy a sense of community minorities (irish italians, lationos, blacks) take pride in being a minority...I do not see an issue...

stanley

ps. housekeeping re You can use some HTML tags, such as ... how do i untag...

Doug said...

Stanley, it was time for a new post. You and Andy and others should feel free to continue this conversation as long as you wish.

I think the way to untag in HTML is always: < / whatever the opening tag was >

So, for example, to bold a word you type < b >bolded word < / b > (but without the spaces.)