tag:blogger.com,1999:blog-74008572024-03-13T08:37:57.639-07:00Developmental Disability System ReformInformation and Rumination about changes to California's community-based system for people with developmental disabilities.Doug The Unahttp://www.blogger.com/profile/04753071669562594194noreply@blogger.comBlogger151125tag:blogger.com,1999:blog-7400857.post-39882729527713511752014-04-30T16:54:00.003-07:002014-04-30T16:54:59.902-07:00Formal Learning: Data, Big Data and Statistics.<div dir="ltr" style="text-align: left;" trbidi="on">
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The first challenge we can call an input problem. Developmental disabilities are defined statistically for the most part. In statistics</div>
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This will start what I hope will be a series on formal learning in individualized services. Because I sometimes read, and all the writing these days is about big data (100.5%.) There are corners of the system (almost vacant of service providers and probably of families) that hope that collecting outcomes data will lead to better services. I think that hope should live on, but that people understand that the benefit will be much less direct than in other sections of the economy.</div>
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To give a quick overview of "big data" and its benefits, now that so much of what we interact with generates information and the capacity to store and analyze it so much vaster than it had been, that humans have grown much much abler to discern patterns that had escaped us in the past. The opportunity to make change comes when we are able to see those patterns in context. Using statistics, we can find what factors affect the patterns we are concerned with the most. The term of art for the factor most relatable to changing a pattern is "the big coefficient." Terms of art in statistics are still pretty arcane and prosaic.</div>
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From my spot on the spectrum, individualized services ought to include the search for, identification and exploitation of patterns along with respect, protection and kindness. And math, particularly statistics, are the handiest tools we have with which to do that. And the rest of this series, if and when it emerges, will be about why I think professional caregivers should do math. But there are reasons to question whether big data can have the same impact in this field that it already has in medicine, marketing, science, politics or engineering.<br />
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<a href="http://www.robertniles.com/stats/graphics/normal.gif" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="http://www.robertniles.com/stats/graphics/normal.gif" style="-webkit-user-select: none; text-align: left;" /></a></div>
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One reason why big data will have trouble helping us help the people we serve might be called an input problem. Just to clarify nomenclature, to the left is what is called a "normal distribution." Of any given naturally occurring trait, there is a central tendency where any random individual is most likely to fall. That is called the mean and can be pictured as a line through the highest part of the curve. Where the curve flattens out to the left and right is called "the tails." I bring this up just because the word "tails" can give either the sense of disparaging or adorable and I wouldn't want to be thought to mean either.<br />
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But most disabilities are defined at least in part by a trait being found in an individual to occur in the tail of the distribution. You can imagine a stone dropped in still water. Where the stone strikes, you get the most information and further along in the eddy you get less. Not only are the people we serve rare, but it is easier using statistics to learn about commoner individuals than about rarer ones. Which is just to say that coca-cola will still know more about refreshment-seekers than DDS will about people with developmental disabilities even after the latter starts really trying.<br />
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The other problem we can call an output problem. When KFC wants people to eat more chicken, it is easy to find factors that correlate with the sought behavior. If the state wants fewer people to be poor, it is relatively easy to use large data sets to figure out which factors have the profoundest impact (largest coefficient) on poverty and proliferate them. But the Lanterman Act and those of us who serve it, wants people to live the lives they choose, not to behave according to a standard. And that makes it much harder to find the large coefficient independent variables.<br />
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So now I hope to write upcoming posts about why measurement and math belong in the complex of tools states and their agents use in pursuit of our mission. But I hope this post set some boundaries on how much we can hope to accomplish this way.</div>
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Doug The Unahttp://www.blogger.com/profile/04753071669562594194noreply@blogger.com7tag:blogger.com,1999:blog-7400857.post-174131296026494592014-04-22T09:08:00.000-07:002014-04-22T09:08:00.114-07:00Why a "cost-based funding model" required a team of smarties to promote.<div dir="ltr" style="text-align: left;" trbidi="on">
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<b>It should</b> be an axiom of policy discussion that any words joining "model" in a phrase are euphemistic. The Lanterman Coalition put forward an 8-or-so point platform together which is sadly circulating. Of the points on their platform, in all likelihood, restoration of Early Start was the most meritorious and the most inevitable. </div>
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In part I turn my attention to the plank advocating a "cost-based funding model" to partly offset the shrugs and nods likely to greet the proposal but more because I think that proposal is emblematic of the worst habits of advocates. It is the south pole of advocacy, the place from which every direction is up. </div>
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To translate "cost-based funding model" into English, the policy proposed is that the correct cost of services is determined by what the service provider spends. Greybeards like me will recall this policy as the predominant one in 2002 at the dawn of a dozen catastrophic years. Advocates like me and many of my friends on the Lanterman Coalition spent a great deal of time in Sacramento arguing that the model was unsustainable without an enormous increase in state funding. Those of us who are eager to try the case that a $5 billion system needs to be a $12 billion system, which is to say, those of us eager to revisit 2002-2013 have their agenda and a coalition of statewide agencies for partners.</div>
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Another problem with the cost-plus model, other than that it quickly becomes a cost-minus model, is that true costs are hard to discover. Translating the specific term "cost-based" from the original euphemism is "spending-based," a quantity that is not dependably related to necessary or constructive expenditures.</div>
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I will post soon about some reasonable alternatives, but the point I would get across in this post, is that anyone ready and willing to learn from experience, after the last dozen years and with the next dozen in prospect, should include sustainability as a principle of any system for which we would or should advocate. I agree with my friends that the system is underfunded to do what it is meant to do the way it currently does it. At least some of our advocacy needs to focus on sources of waste, potential sources of formal intelligence and engineering resilience into the system.</div>
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It isn't clear that a fully funded status quo would sensibly improve lives for people with developmental disabilities, but taxpayers surely would notice.</div>
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Doug The Unahttp://www.blogger.com/profile/04753071669562594194noreply@blogger.com3tag:blogger.com,1999:blog-7400857.post-17197917631917153782014-03-19T07:43:00.000-07:002014-03-19T07:44:36.061-07:00A New Beginning, CQI edition<div dir="ltr" style="text-align: left;" trbidi="on">
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Hello, old friends;</div>
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New purpose on this blog: To discuss 30,000 foot, big picture issues as Executive Director of Imagine SLS with our community of clients, staff, families, colleagues and, of course, my old friends from this blog if you return. The main difference will be: more focus on things as Imagine experiences them and less focus on controversial political issues. A secondary difference will be more aggressive deleting of comments which seem antagonistic. A little less beerhall and more tea salon.</div>
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That said, the purpose of this blog will be to explain what passes through what passes for a mind in the Executive Director of imagine and to solicit input. No individual client issues will be discussed, obviously, nor matters with individual staff and in that sense the focus will be what it has been: How Imagine and other agencies can better perform for the people we serve and the communities those people share.</div>
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The first series will be about some of the thinking behind our all-staff training in May. Interested staff can walk into that meeting with extra awareness of the substance of the training and having helped to shape it.</div>
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Doug The Unahttp://www.blogger.com/profile/04753071669562594194noreply@blogger.com3tag:blogger.com,1999:blog-7400857.post-5824353856010499922013-05-30T17:19:00.001-07:002013-05-30T17:19:15.092-07:00Masonite<div dir="ltr" style="text-align: left;" trbidi="on">
The typical non-profit board is composed of wealthy people, connected people and interested people. In California's DD system, I wonder how many people working at similar agencies sit on boards. Granted, there's a conflict of interest inherent in the idea and it might be a terrible idea and all but here is a way this would help: Few trustees/directors of non-profit agencies serving individuals within the regional center system have a good idea how to do what the agency is meant to do.<br />
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That could be leaving gaps in how well boards hear and understand the budgets and proposals that come before them. On the other hand, I might just be grouchy while I wait to hear about my budget.<br />
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Doug The Unahttp://www.blogger.com/profile/04753071669562594194noreply@blogger.com1tag:blogger.com,1999:blog-7400857.post-38492848127055578922013-05-24T07:16:00.002-07:002013-05-24T07:19:28.917-07:00Episode IV: A New Beginning<div dir="ltr" style="text-align: left;" trbidi="on">
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Hello, friends;</div>
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A project that I am working on with a good friend, colleague and fellow villain/service provider will rely on skills that I've allowed to lapse or never learned and one of those is writing for the web. So I've decided to revive this here blog.</div>
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A few things have changed since last I posted here, thick-haired and hopeful. I no longer run a small agency but am a mid-level manager at a larger one. For that reason, I feel a duty to be a little more careful and a little less breezy about causing offense. Some of the alleged "stridency" that was a feature here will be intentionally curtailed. But I think there are still thoughts, big ideas and revolutionary manifestos to discuss as well as sarcasm to levy.</div>
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I hope my companions of yore will come back and join me. Anybody still out there? Or are you all wasting your lives on social networks instead of living richly on blogger?</div>
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Doug The Unahttp://www.blogger.com/profile/04753071669562594194noreply@blogger.com25tag:blogger.com,1999:blog-7400857.post-84744910636497457312011-09-01T08:31:00.000-07:002011-09-01T08:31:31.888-07:00Policy, Choice and the Lanterman Act<div dir="ltr" style="text-align: left;" trbidi="on">
A friend sent me <a href="http://keepingthelantermanpromise.net/inform/we-should-not-allow-california-to-adopt-a-policy-saying-that-every-adult-with-a-developmental-disability-should-work-in-integrated-competitive-employment/">this link</a>. The concern (in the blog post linked) is that with a new state policy promoting integrated employment as a goal for every adult, that the individualization will be lost. In response, I feel torn between two cynicisms. On the one hand, state policy has little enough to do with actual practice that I would gladly accept a state policy stating the purpose of the regional center system as "for the enablement of the deaths-by-torture of vendor managers" for a small rate increase or the right to taze service coordinators who fail to convene ID teams. If we are honest, there is no catastrophe here. The most I expect the policy change to cause is a few bad meetings and series of sanctimonious speeches. Who'll notice? <br />
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On the other hand, I can share the writer's annoyance this far: Policy statements less substantial than a dentist's breath are a bad habit that promotes other bad habits. That we can safely divorce such statements from outcomes has made it all too easy to also divorce outcomes from our thinking. In turn, that makes ridiculous policy positions much more acceptable (c.f. the opening paragraph.) Does anyone doubt that the widening divergence of policy and practice hinders system reform for cost's sake or for quality's?<br />
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So, pretending for a moment that I take this seriously, here are some concerns:<br />
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<li>We have a very hard time at consistently distinguishing between aspirations, moral imperatives and greedy shenanigans. It may not be clear, for example, whether it is better to be unemployed in the competitive labor market or productive at a site-based program. Were the policy implemented at all, it would undoubtedly be implemented inconsistently and in many cases counter-productively.</li>
<li>If we really want to streamline the system, it is never, in my experience, less efficient than when we try to help people do what they don't want to, and nothing is easier to sabotage than employment. How many hours of needed ILS, SLS, respite and vocational development would be cut or reallocated to support heroic efforts to find jobs for people who don't want them or aren't comfortable in an integrated setting, all in an environment where people who do want jobs can't find them?</li>
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All of this said, I agree with the state that every adult served by the system who is not employed in a competitive, integrated, profitable position ought to be a sign that something should be improved.</div>
Doug The Unahttp://www.blogger.com/profile/04753071669562594194noreply@blogger.com19tag:blogger.com,1999:blog-7400857.post-43894206273179333042011-07-06T09:48:00.001-07:002011-07-06T10:03:05.304-07:00Did DDS cut something correctly?<div style="text-align: justify;">When I hear from worried vendors concerned about cuts, much or most of the dyspepsia is over the limitation to 15% administration in negotiated rates. There certainly can be a case against that cut. People who live on their own and can't use the commonest forms of communication are highly vulnerable and for those of us who serve such people, their best protection is not the regional center, or the area board or in many cases families but oversight from the administration of their service provider. Furthermore, to the extent that we are careful and detailed as a system, there will be many cases when service designs will have to be revised to bring down overhead and those revisions may not have a smooth path to follow.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">However, my instinct tells me that the greatest flaws in the budget-cutting regime over the last years has been the combination of rigidity with uncertainty. Consider my personal black beast, the new audit requirements. The cost of that requirement, it seems safe to predict, will reach the tens of millions of dollars per year systemwide in purely administrative costs. Those costs are real, certain, specific, mandatory and tangible. But the mechanism by which that requirement will save the state money is hypothetical. To be kinder, I suppose we could say hopeful. </div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">By comparison, the 15% cap can be at least anecdotally supported as a way of saving money and the combination of vendor, client and regional center have a fair degree of flexibility to decide what features of the support should be sacrificed to reach a clear threshold. Of course, the same combination is also empowered to launder their way out of savings via reclassification of effort, but still. To the extent that it works, the cut can be tailored to protect the needs of the consumer, the competency of the provider and the preference of the regional center.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">Apart from Stanley, anybody out there want to give DDS credit for this? Or are there other cuts that seem smart to you?</div>Doug The Unahttp://www.blogger.com/profile/04753071669562594194noreply@blogger.com37tag:blogger.com,1999:blog-7400857.post-56020027705644514052011-03-27T10:51:00.000-07:002011-03-27T10:57:11.923-07:00ILS/SLS WorkgroupsSo, this here workgroup thingabob is open enough to have too many participants but not quite open. Since some of us are representing all of us, CDCAN is holding weekly conference calls for what happens in the meetings to come out. Along those lines, I'll post my input to the group here.<div><br /></div><div>Email sent 3/25:</div><div><div style="font-family: Helvetica; font-size: medium; "></div><blockquote><div style="font-family: Helvetica; font-size: medium; "><i>Due to the inspired (yet stern) leadership of Tammy Bachrach, ELARC VAC chair, we spent the bulk of our meeting yesterday divided into tables based on the workgroups. The ILS/SLS group recognized that the legislature has changed their focus from service standards to "best practices," so we allowed ourselves the liberty of focus on cost-saving practices around ILS and SLS. Following are suggestions from the group.</i></div><div style="font-family: Helvetica; font-size: medium; "><i><br /></i></div><div style="font-family: Helvetica; font-size: medium; "><b><i>For ILS</i></b><i>: It was suggested that we might get more realistic service plans if, when a referral is made for a new ILS client, that in addition to the agencies referred to serve the client, a different ILS agency be referred the task of writing the initial assessment. The suggestion recognizes that when an agency writes its own initial assessment, even the honest and wise among us have a natural bias towards overestimating the need (although probably not by a lot, demagogues.) The assessing agency would have to agree not to work with the assessed client for at least a year.</i></div><div style="font-family: Helvetica; font-size: medium; "><i><br /></i></div><div style="font-family: Helvetica; font-size: medium; "><i>There are some down-sides to this to be concerned with. One is just that regional centers might prefer agencies that write emaciated service plans. It would be important that the assessing agencies also be serving ILS clients and that the assessor rotate. Also, in areas where there is only one or two ILS providers this arrangement will not be possible. An objection from the group was that the assessment serves an important function of developing a mutual understanding between a new vendor and a new client. </i></div><div style="font-family: Helvetica; font-size: medium; "><i><br /></i></div><div style="font-family: Helvetica; font-size: medium; "><i>All of that said, I think the idea has merit and should be discussed.</i></div><div style="font-family: Helvetica; font-size: medium; "><i><br /></i></div><div style="font-family: Helvetica; font-size: medium; "><b><i>For SLS</i></b><i>: There were two suggestions. Unlike the ILS suggestion, these had unanimous support in our discussion group.</i></div><div style="font-family: Helvetica; font-size: medium; "><i><br /></i></div><div style="font-family: Helvetica; font-size: medium; "><i>1. It was felt that benefit appeals specialist (particularly, but not exclusively regarding IHSS) may be more efficient than some agencies at insuring that IHSS hours are covered by IHSS rather than the regional center or an agency. The proposal is that regional centers cultivate these advocates and vendors that choose this assistance would surrender a portion of their administrative funding proportional to their expected benefit management cost.</i></div><div style="font-family: Helvetica; font-size: medium; "><i><br /></i></div><div style="font-family: Helvetica; font-size: medium; "><i>2. If somebody could, for heaven's sake, do something about worker's compensation costs for SLS providers, those providers would be thrilled to surrender a like amount of their hourly rate.</i></div></blockquote><div style="font-family: Helvetica; font-size: medium; "></div></div><br />Email sent 3/27:<br /><div><br /></div><div><span class="Apple-style-span" style="font-family: Helvetica; font-size: medium; "></span><blockquote><span class="Apple-style-span" style="font-family: Helvetica; font-size: medium; "><i>Hi, all. Me again. FIrst, to commend Scott. I think that was a nice job. The only exception I'd take is that some level of skill-development service ought to be available to clients living with family do not intend to change their home setting immediately. Whether that service is provided under the myth of Adaptive Skills Training rather than the myth of Independent Living Skills, makes no difference I can see.</i></span><div style="font-family: Helvetica; font-size: medium; "><i><br /></i></div><div style="font-family: Helvetica; font-size: medium; "><i>Something that has been on my mind which is related to the topic at least: (The following is written in a prophetic voice, by which I mean I hope to be heard but don't really expect to be listened to, a la Jonah in Ninevah)</i></div><div style="font-family: Helvetica; font-size: medium; "><i><br /></i></div><div style="font-family: Helvetica; font-size: medium; "><i>A lean system has to be a smart system and our system is never less smart than when it is focused on some sort of reform having to do with vendor codes and categories. Regional Center staff, forced by the nature of the regional center's role to make policy with a minimum of information and a maximum of effect, tend towards involuntary glibness and in my experience lose what concentration and permeability they otherwise retain when the topic of vendor codes is on the table.</i></div><div style="font-family: Helvetica; font-size: medium; "><i><br /></i></div><div style="font-family: Helvetica; font-size: medium; "><i>Likewise, vendor executives, already prone to priestly grandeur and martyrdom (cf, this email,) are never more divisive, sanctimonious and grasping as when we contest our vendor codes (excepting, of course, when unions sponsor bills.) </i></div><div style="font-family: Helvetica; font-size: medium; "><i><br /></i></div><div style="font-family: Helvetica; font-size: medium; "><i>To direct care staff and clients, vendor codes represent less than nothing. I don't believe anyone who will be in the room Monday would be able, watching individualized support delivered, to identify the vendor code under which delivery takes place. Either services are led by the client and his or her needs and abilities under the influence of a circle of support or not. If so, the service itself is probably efficient, whether or not the referral process or agency supervision, for example, are. If not, it's wasteful of taxpayer money and negligent of the value clients have the right to expect. I believe that any discussion of reform that focuses on category or code is likewise wasteful of scarce funding and negligent of important support.</i></div><div style="font-family: Helvetica; font-size: medium; "><i><br /></i></div><div style="font-family: Helvetica; font-size: medium; "><i>So my concern with the work of our group is that it represents a deepening of our reliance on irrelevancies and distractions in defining the value we deliver and setting its price; and steps further away from efficiency and smartness in our system. The legislature has opened an opportunity to be brighter by changing the administration's proposal of "purchase of service standards" to a proposal of "best practices." Granted, that was a bad use of nomenclature but an improvement in focus. I do hope we can take advantage of this. As I said, I don't mean to change the agenda, but I would point out that most of the work we've accomplished so far has been the delivery of data and instructions from DDS and the return of criticism. I don't think much achievement will have been undone if we change our focus. </i></div><div style="font-family: Helvetica; font-size: medium; "><i><br /></i></div><div style="font-family: Helvetica; font-size: medium; "><i>There is work to be done in how and why clients are assigned for agencies and services, work to be done on how vendors deliver that service. Granted that our services must always be individualized, it isn't necessarily the case that all regional centers and vendors need all of their processes to be idiosyncratic for that purpose. There must be opportunities for service delivery to become leaner which would lead us in a better and smarter direction than a discussion of standard hours or normal eligibility. Since by any name we are really talking about budget cuts, I would hope those cuts could be as much as possible to process rather than to support.</i></div><div style="font-family: Helvetica; font-size: medium; "><i><br /></i></div><div style="font-family: Helvetica; font-size: medium; "><i>In sincere friendship and admiration (but with a pinch of sarcasm by which old friends recognize me,)</i></div><div style="font-family: Helvetica; font-size: medium; "><i><br /></i></div><div style="font-family: Helvetica; font-size: medium; "><i>Doug</i></div><div style="font-family: Helvetica; font-size: medium; "><i><br /></i></div><div style="font-family: Helvetica; font-size: medium; "><i>May God bless and keep you, make his face shine upon you and be gracious unto you. Amen.</i></div></blockquote><div style="font-family: Helvetica; font-size: medium; "></div></div>Doug The Unahttp://www.blogger.com/profile/04753071669562594194noreply@blogger.com17tag:blogger.com,1999:blog-7400857.post-16130288692635193482011-02-17T17:08:00.000-08:002011-02-18T10:40:13.505-08:00Forecast<div style="text-align: justify;">Alongside "draconian," "savage," "irresponsible," "responsible" and "common sense," "darwinian" is an adjective that deserve to modify the cuts in process. Still, there seems to be little discussion of how the system will evolve in the presence of significantly less funding and new regulations. To the extent that there's a vision for change, it seems to be towards accountability, a welcome new feature, if the new accountability systems proposed didn't seem as spectacularly inefficient as the worst images of the system and if there were some little bit of the new oversight that addressed outcomes.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">But as to the composition of the system, I have a very hard time believing that will not change over the next year. What has frustrated me the most watching the changes so far has been the lack of intentionality to it all. In essence, real cuts have come with implementing statute which in at least half the cases was implausible. This has left it to regional centers to cut services not mentioned in the trailer bills. So, from the be the change you seek department, here is my projection for the system we are now creating.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b>Congregate care will be much more prominent on the menu of options, and large providers will dominate:</b> Larger non-profits, with some notable exceptions such as Jay Nolan Community Services, are principally site-based, secondarily group-based, and often have individualized services attached as tiny portions of the whole. They are also more likely to be non-profit and to fund-raise successfully. These services have been unsuccessfully targeted for cuts. But are the best placed to weather them and have generally avoided implementation of most, leading to cuts not targeted in individualized care.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">There will almost certainly be fewer providers in the future. Parent-providers may continue and large agencies should survive but the smaller agencies that comprise most of the individualized system will be less sustainable. These agencies may merge with one another to survive, or close. To the extent that large non-profits are willing and able to provide ILS, SLS, micro-enterprise support or that smaller agencies can merge, person-centered services may continue to be available. But it is worth noting that under the hedgehog principle that firms specialize for a reason, it seems worth noting that at large agencies that provide both congregate and individualized support, ILS and SLS et cetera are usually very small pieces of overall programming.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><i>Note</i>: For the purpose of this post I am not assuming that this is a bad thing for people with disabilities, but I also do not assume this will make care more efficient. While congregated services are cheaper per person and per hour, clients receiving individualized support often require much less of it. I think it would be impossible to say based on data we have whether the site-based system is more or less efficient than its alternative. For example, micro-enterprise and job-coaching are much more common than workshops or enclaves with clients of ILS and SLS services which eliminates a lot of bureaucracy. </div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">Moreover, changes rarely go well without planning and, thus far, DDS has been scrupulous in spreading damage to the system fairly evenly. As a consequence, whatever system change will come is likely to favor not cost-savings nor efficiency, nor quality but the fiscal positions of the providers. Fortunately for everyone, blogging is a low-overhead activity.</div>Doug The Unahttp://www.blogger.com/profile/04753071669562594194noreply@blogger.com0tag:blogger.com,1999:blog-7400857.post-17084352602539034052011-02-16T18:29:00.000-08:002011-02-16T18:41:53.985-08:00In praise of the monkey<div style="text-align: justify;">I had a recollection this morning of the old system-reform workgroups. The purpose as given was to make changes to the system, in partnership between DDS and other stakeholders, for the purpose of producing more value for the people the system served. All of the conversations, however, wound up focused on making the system more expensive. Better ideas were quickly forgotten in favor of silly ones. More than once since then, I've wondered what it takes to get sincerity and mission from experienced advocates. As much as anything, that question led to my ongoing support for CDCAN.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">So, with that in mind, I like the survey monkey DDS employed for ideas regarding purchase of service standards. I'm skeptical that the resulting standards will be any less foolish than much of the existing trailer bill language. Even DDS, which is trying to reduce funding, can't seem to complete a thought on reform without bloating the cost of the system. (I would credit them for paying attention during the system reform.) But at least they are getting input some of which will be candid and thoughtful. I hope DDS continues to solicit feedback broadly and do hereby award them three bananas for current efforts.</div>Doug The Unahttp://www.blogger.com/profile/04753071669562594194noreply@blogger.com0tag:blogger.com,1999:blog-7400857.post-76559307993535320142011-02-11T17:13:00.000-08:002011-02-11T17:18:56.871-08:00A few notes on things as they areJust a couple quick observations from the hearing 2/10.<div><br /></div><div>First, Ms. Delgadillo used the continuing availability of new vendors in response to a question regarding the affect of existing rate cuts. It bears noting that new vendors receive higher rates than the older vendors that currently have most of the capacity. The number of agencies closing, assuming it is small, might be evidence that rate cuts aren't too damaging but the number of new vendors is entirely irrelevant as a datum.</div><div><br /></div><div>Second, the audit suggestion depresses me. DDS needs to find ways of lowering the cost of the system other than by raising the cost of the system. </div>Doug The Unahttp://www.blogger.com/profile/04753071669562594194noreply@blogger.com7tag:blogger.com,1999:blog-7400857.post-18936877336010754432011-02-04T14:40:00.000-08:002011-02-04T18:56:14.391-08:00Things DDS (or LAO) should be thinking about, Part I<div style="text-align: justify;"><span class="Apple-style-span" style="font-family:'times new roman';"><span class="Apple-style-span" style="font-size: medium;">While DDS plays with service standards and administration costs and other proposals from which the unforeseen consequences will outnumber the planned reforms by 1,000 to one, there are some foreseeable scenarios for which planning could mitigate harm </span></span><em><span class="Apple-style-span" style="font-family:'times new roman';"><span class="Apple-style-span" style="font-size: medium;">and</span></span></em><span class="Apple-style-span" style="font-family:'times new roman';"><span class="Apple-style-span" style="font-size: medium;"> reduce costs. Here is my list:</span></span></div><div style="text-align: justify;"><span class="Apple-style-span" style="font-family:'times new roman';"><span class="Apple-style-span" style="font-size: medium;"><br /></span></span></div><div style="text-align: justify;"><strong><span class="Apple-style-span" style="font-family:'times new roman';"><span class="Apple-style-span" style="font-size: medium;">Consolidation is inevitable. </span></span></strong><span class="Apple-style-span" style="font-family:'times new roman';"><span class="Apple-style-span" style="font-size: medium;">The cuts the governor has proposed are more than the system can bear, but even without further cuts, many agencies are now unsustainable and there will be further cuts. What's more, there is no likelihood that the cuts as proposed will be the cuts as experienced. Things intended no longer to be compensated will be paid for and things left protected will be cut. Agencies will reach the point that they are no longer large enough to justify management and those agencies will start to close. The clients served by those agencies will in most cases receive new supports from different agencies.</span></span></div><div style="text-align: justify;"><span class="Apple-style-span" style="font-family:'times new roman';"><span class="Apple-style-span" style="font-size: medium;"><br /></span></span></div><div style="text-align: justify;"><span class="Apple-style-span" style="font-family:'times new roman';"><span class="Apple-style-span" style="font-size: medium;">Barriers to sale or merger of existing agencies can be removed, allowing the clients to avoid interruption of important relationships and lowering the administrative burden on both regional centers and vendors from the reallocation of those clients. The alternative is the existing process which is needlessly traumatic for clients and staff and needlessly costly for agencies and the state.</span></span></div><div style="text-align: justify;"><span class="Apple-style-span" style="font-family:'times new roman';"><span class="Apple-style-span" style="font-size: medium;"><br /></span></span></div><div style="text-align: justify;"><b><span class="Apple-style-span" style="font-family:'times new roman';"><span class="Apple-style-span" style="font-size: medium;">The savings in the Bureau of State Audit reports are between the headlines</span></span></b><span class="Apple-style-span" style="font-family:'times new roman';"><span class="Apple-style-span" style="font-size: medium;">: So far, trailer bill language coming from DDS seems focussed on the most lurid offenses the BSA found in its work. I can certainly agree that IRC's budget-padding ought to be cut off and extra funding for relatives of regional center employees ought to be cut off. But booking savings seems foolish. It strikes me unlikely that any new statute will prevent miscreants and thieves employed by regional centers from spending any new money in ways that their colleagues have been caught. </span></span></div><div style="text-align: justify;"><span class="Apple-style-span" style="font-family:'times new roman';"><span class="Apple-style-span" style="font-size: medium;"><br /></span></span></div><div style="text-align: justify;"><span class="Apple-style-span" style="font-family:'times new roman';"><span class="Apple-style-span" style="font-size: medium;">But between the headlines were examples of how regional centers may waste money in small ways every day. To someone working in this system, a family member of someone who is a client in this system, the anecdote of the regional center employees explaining a contracting decision with an undocumented, unexplained preference resonated with countless experiences repeated so regularly I'd stopped noticing until I saw it in print. The new trailer bill language regarding large contracts might have prevented one $950,000 absurdity but perhaps never another. Reviewing vendor selection by regional centers by sampling the tens of thousands of opportunities that arise each year to be unintentionally inefficient holds much more promise. </span></span></div><div style="text-align: justify;"><span class="Apple-style-span" style="font-family:'times new roman';"><span class="Apple-style-span" style="font-size: medium;"><br /></span></span></div><div style="text-align: justify;"><span class="Apple-style-span" style="font-family:'times new roman';"><span class="Apple-style-span" style="font-size: medium;">As someone who has encountered both wild bears and domestic termites, I assure my friends in Sacramento that common, small pests do much more damage than big rare ones.</span></span></div><div style="text-align: justify;"><span class="Apple-style-span" style="font-family:'times new roman';"><span class="Apple-style-span" style="font-size: medium;"><br /></span></span></div><div style="text-align: justify;"><b><span class="Apple-style-span" style="font-family:'times new roman';"><span class="Apple-style-span" style="font-size: medium;">Look differently at rates</span></span></b><span class="Apple-style-span" style="font-family:'times new roman';"><span class="Apple-style-span" style="font-size: medium;">: One way this system was meant to be efficient was competition. The problem is that there has never been a good tool for regional centers to use to reliably (or semi-reliably) judge quality and rates are opaque, so whatever providers compete on the basis of, it isn't quality and it isn't cost. </span></span></div><div style="text-align: justify;"><span class="Apple-style-span" style="font-family:'times new roman';"><span class="Apple-style-span" style="font-size: medium;"><br /></span></span></div><div style="text-align: justify;"><span class="Apple-style-span" style="font-family:'times new roman';"><span class="Apple-style-span" style="font-size: medium;">This has a couple implications. First, rates should be public so that agencies can compete on that basis. Second, it means that for the most part, the state is paying whatever rate was given to whatever agency was chosen on whatever basis. In the short term, if further rate cuts are anticipated, given that the rates are close to random, it would be better to cap rates than to continue hurting the low cost providers by the same percentage as the expensive ones. The usual justification why the rate system is so irrational has always been that to rationalize it would cost some agencies and they'll fight the change. That's still true, but seems pretty important in the present circumstances.</span></span></div><div style="text-align: justify;"><span class="Apple-style-span" style="font-family:'times new roman';"><span class="Apple-style-span" style="font-size: medium;"><br /></span></span></div><div style="text-align: justify;"><span class="Apple-style-span" style="font-family:'times new roman';"><span class="Apple-style-span" style="font-size: medium;">But rates ought to public and regional centers and/or DDS ought to publish them. That will make it a little harder for regional centers to neglect that consideration and a little harder for high-cost vendors to hype their own costs. Furthermore, it would help in negotiations as the fear of being cheated could be as completely allayed as it is possible to allay that particular phobia.</span></span></div><div style="text-align: justify;"><span class="Apple-style-span" style="font-family:'times new roman';"><span class="Apple-style-span" style="font-size: medium;"><br /></span></span></div><div style="text-align: justify;"><b><span class="Apple-style-span" style="font-family:'times new roman';"><span class="Apple-style-span" style="font-size: medium;">Query to readers</span></span></b><span class="Apple-style-span" style="font-family:'times new roman';"><span class="Apple-style-span" style="font-size: medium;">: What do you think DDS should be considering while they write the trailer bill language? (Leave a comment and then go </span></span><a href="http://www.dds.ca.gov/survey/"><span class="Apple-style-span" style="font-family:'times new roman';"><span class="Apple-style-span" style="font-size: medium;">tell them</span></span></a><span class="Apple-style-span" style="font-family:'times new roman';"><span class="Apple-style-span" style="font-size: medium;">.)</span></span></div><div style="text-align: justify;"><br /></div>Doug The Unahttp://www.blogger.com/profile/04753071669562594194noreply@blogger.com5tag:blogger.com,1999:blog-7400857.post-14502143334807250352011-01-21T14:24:00.000-08:002011-01-21T14:27:42.898-08:00QuestionsMarty Omoto reported today that the Department of Developmental Services will publish its process for identifying cuts. That's a good thing, although the coincident report that the new trailer bill language will be available next week suggests it won't be much of a process. I'm left wondering if DDS, which has now had two years of near certainty that further cuts were coming to think about this. I'm curious whether they will seek to reduce costs generally or in a targetted way. In other words, machete in the daytime or grapefruit spoon in the dark?<div><br /></div>Doug The Unahttp://www.blogger.com/profile/04753071669562594194noreply@blogger.com5tag:blogger.com,1999:blog-7400857.post-64832650307221958722010-08-08T10:33:00.000-07:002010-08-08T10:38:44.261-07:00About the ExaminerSo, I thought I would begin the new dealybob at Examiner.com with an explanation of what I would write as a reference for any future readers who would happen by. That first post was rejected, probably appropriately, for being too much in the first person. But, just to share, here is what it would have said.<div><br /></div><div>***</div><div><br /></div><div><p style="margin: 0.0px 0.0px 12.0px 0.0px; font: 12.0px Arial; color:#232323;"><span style="letter-spacing: 0.0px"><b>Welcome</b>,</span></p> <p style="margin: 0.0px 0.0px 12.0px 0.0px; font: 12.0px Arial; color:#232323;"><span style="letter-spacing: 0.0px">This will be my first article as an Examiner (and so, the oldest one in my eventual archive.) It's a good place to predict what this column will cover. Consider this half a promise and half a bet, if there are takers for either.</span></p> <p style="margin: 0.0px 0.0px 12.0px 0.0px; font: 12.0px Arial; color:#232323;"><span style="letter-spacing: 0.0px">This column will cover events, trends and policies related to the provision of human and social services. Professional caregiving is often publicly funded and usually highly-regulated so public policy will be discussed extensively, but market forces and demographics will also be considered. Sporadically, we in the social services think about actual people, so expect occasional profiles of people with disabilities, policy-makers, caregivers, charlatans and reprobates.</span></p> <p style="margin: 0.0px 0.0px 12.0px 0.0px; font: 12.0px Arial; color:#232323;"><span style="letter-spacing: 0.0px"><i>About me</i>: I work in the social services industry as the chief executive of a small for-profit company that assists adults with developmental disabilities to live independently, as a subcontractor to state contractors. We will soon offer companion services to the elderly and physically disabled.</span></p> <p style="margin: 0.0px 0.0px 12.0px 0.0px; font: 12.0px Arial; color:#232323;"><span style="letter-spacing: 0.0px">There is a phrase in the paragraph just above to make anyone skeptical, so here are the biases I'll admit to up front-</span></p> <ol style="list-style-type: decimal"> <li style="margin: 0.0px 0.0px 0.0px 0.0px; font: 12.0px Arial; color:#232323;"><span style="letter-spacing: 0.0px">There are two principle purposes for having a social and human services system, to defend the threatened and to extend community participation beyond the barriers that nature and circumstance impose.</span></li> <li style="margin: 0.0px 0.0px 0.0px 0.0px; font: 12.0px Arial; color:#232323;"><span style="letter-spacing: 0.0px">Services provided through government tend to be both inefficient and underfunded for their missions. The former defect makes a bigger difference than the latter and is more fixable. Inefficient service delivery creates costs not only to the taxpayer but also to the people who depend on the support provided, through malarkey.</span></li> <li style="margin: 0.0px 0.0px 0.0px 0.0px; font: 12.0px Arial; color:#232323;"><span style="letter-spacing: 0.0px">Purely private services may (or may not) be more efficient, reliable and of higher quality but are also extremely rare. Very few of us will ever receive professional care not influenced by public policy.</span></li> <li style="margin: 0.0px 0.0px 0.0px 0.0px; font: 12.0px Arial; color:#232323;"><span style="letter-spacing: 0.0px">Ideology drives idiots crazy, madmen to folly and reasonable people to fake deafness. This column will be very interested in the granular details of what works and doesn't work in both regulation and the marketplace. Democrats, Republicans, vampires of both union and capitalist varieties, dithering managers and doddering staff all may receive attention here, some of which may be complimentary.</span></li> <li style="margin: 0.0px 0.0px 0.0px 0.0px; font: 12.0px Arial; color:#232323;"><span style="letter-spacing: 0.0px">I am a reformer, may heaven have pity and my neighbors patience.</span></li> </ol> <p style="margin: 0.0px 0.0px 12.0px 0.0px; font: 12.0px Arial; color:#232323;"><span style="letter-spacing: 0.0px">Sounds fun, right? I welcome your comments.</span></p><div><br /></div><div><br /></div></div>Doug The Unahttp://www.blogger.com/profile/04753071669562594194noreply@blogger.com40tag:blogger.com,1999:blog-7400857.post-88003529913503731932010-07-21T14:38:00.000-07:002010-07-24T02:23:22.144-07:00Brand new bagHowdy and a quick announcement. I am now writing generally about social services, human services and professional caregiving for <a href="http://examiner.com/">Examiner.com</a>. It's something slightly closer to a job than this blog has been. The new site will take most of the effort I've been putting into this site (roughly 1400%) and be less focussed on developmental disabilities. I'll keep this site so Andy and Stanley have somewhere to rant and I can get deep in the policy weeds from time. The link to my new page is in the title of this post.<div><br /></div><div>You're all welcome to join the conversation there.</div>Doug The Unahttp://www.blogger.com/profile/04753071669562594194noreply@blogger.com16tag:blogger.com,1999:blog-7400857.post-26245698312669078422010-07-06T08:22:00.000-07:002010-07-06T11:12:49.668-07:00Talking cents<div style="text-align: justify;"><span class="Apple-style-span" style=" ;font-size:15.9722px;">The dollars needed to preserve the system will not be forthcoming, I'm afraid. Not for a long time, anyway. I believe our choices will be to let it all continue to crumble or start seeing nickels and dimes worth of actual service as more desirable than advocacy denominated in billion dollar bills.</span></div><div style="text-align: justify;"><span class="Apple-style-span" style=" ;font-size:15.9722px;"><br /></span></div><div style="text-align: justify;"><span class="Apple-style-span" style=" ;font-size:15.9722px;">In support of a resolution I've proposed to the San Gabriel/Pomona Regional Center Vendor Advisory Committee, I've recently had the opportunity to retell this story: In 2002 or so, I started receiving a lot of phone calls from Service Coordinators asking me questions that took me by surprise. But they had a pattern: Many asked about the clients' height and weight (useful mostly if you are going on rides at Disneyland or boarding a helicopter;) some asked about the clients' ambulation (useful for special olympics planning;) others asked if the client had been out of service for any extended periods, out of state or hospitalized or in prison (useful for identifying fraud, assuming the same vendor would bill fraudulently and then answer the question diligently.)</span></div><div style="text-align: justify;"><span class="Apple-style-span" style=" ;font-size:15.9722px;"><br /></span></div><div style="text-align: justify;"><span class="Apple-style-span" style=" ;font-size:15.9722px;">The questions were odd and there was no particular place for me to find the answers, so after receiving the calls I would generally get up, search through the client's file and, if that didn't turn up the answer, call the supervisor responsible for the case who would, next time she wasn't with a client search through notes for the answers. Then I would call the SC back with or without the right answer. I don't know how much time SCs were spending on the questions, but Arriba staff were spending several hours per week. </span></div><div style="text-align: justify;"><span class="Apple-style-span" style=" ;font-size:15.9722px;"><br /></span></div><div style="text-align: justify;"><span class="Apple-style-span" style=" ;font-size:15.9722px;">At some point, I found an unimpertinent way of asking "why are you asking?" and the answer came "for the waiver documentation" nine times out of ten. After that I talked to the very smart person in charge of said documentation and we worked out a template, to be included in every progress report, that would answer all of these questions. Staff already, when updating the reports looked in all the places that data would be for the answers to other questions so once we changed our template, the administrative workload here went down sharply and at least some time was saved for the SCs who eventually would learn that the answer was sitting on their own computer. At the very least, the calls per client-question fell from two to one.</span></div><div style="text-align: justify;"><span class="Apple-style-span" style=" ;font-size:15.9722px;"><br /></span></div><div style="text-align: justify;"><span class="Apple-style-span" style=" ;font-size:15.9722px;">Spread that change from Arriba's 100 or so clients to a regional center's some-thousand-and-some, and it might be that half a year of one person's work could be saved. That's not a ton, but it could be enough to turn an administrative position into a service position or a savings. </span></div><div style="text-align: justify;"><span class="Apple-style-span" style=" ;font-size:15.9722px;"><br /></span></div><div style="text-align: justify;"><span class="Apple-style-span" style=" ;font-size:15.9722px;">So, here's a question for commenters who seem to need questions: What are some other small changes that might make the cost of service left while leaving the service intact?</span></div>Doug The Unahttp://www.blogger.com/profile/04753071669562594194noreply@blogger.com11tag:blogger.com,1999:blog-7400857.post-90332071080492594572010-04-07T10:58:00.000-07:002010-04-07T11:17:49.179-07:00The pettiest post on this site<div style="text-align: justify;">This is a very small point, but the conversation around caseload ratios for service coordinators has become too funny to leave be. What I keep hearing is that for HCBS waiver clients, the caseload ratio remains limited to 62:1 but that the cap has been lifted entirely for non-waiver clients. It makes sense that people would say this because neither CMS nor DDS nor anyone else want California to twit the federal government in a way that requires a response.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">But, the assertion keeps getting made without irony or humor or apparent self-awareness so let's just us, we few who discuss here, set the record straight. If the non-waiver caseload is uncapped, then the waiver caseload is also uncapped. The reason I think so: I don't know of a regional center that has waiver and non-waiver caseloads. As far as I know, all service coordinators have mixed caseloads. </div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">This means that that to say "we have a 75:1 caseload ratio" means the same distribution as to say "we have a 62:1 caseload ratio for HCBS clients and a 101:1 ratio for non-waiver clients (assuming 2/3 of clients are on the waiver and I did my math right.) Really, this is a very unimportant point, but I do hope you will join me in smirking whenever you hear someone claim that the caseloads are fixed for waiver clients.</div>Doug The Unahttp://www.blogger.com/profile/04753071669562594194noreply@blogger.com48tag:blogger.com,1999:blog-7400857.post-50389837311409862022010-04-01T07:42:00.000-07:002010-04-02T13:41:22.373-07:00Other closures<div style="text-align: justify;">Much has been made of the pending closure of Lanterman Developmental Center, and it would be to our detriment to ignore the impact of the planned closure of <a href="http://www.lanterman.org/">Lanterman Regional Center</a>. According to DDS Director, Teri Delgadillo, Lanterman is being closed and merged with Harbor and Westside regional centers to save money. As Ms. Delgadillo says in her statement, "The administration considers these three regional centers, which have already harmonized their service coordination process to the degree that client expectations have been regionalized. Furthermore, by pooling staff, the combined regional center will have the capacity to say 'no' in more than 80 languages."</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">"We certainly defer," Director Delgadillo continued, "to the combined 80-person board of the merged center in terms of naming the new facility and appointing management. But DDS personnel are recommending 'Richard Riordan Regional Center,' because we enjoy the sense of whimsy that alliteration brings."</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">Walt Disney Regional Center, which will be created from the merger of South Central and Orange Country RCs will have the capacity to say "please" and "thank you" in more than 30 languages and on legal pleadings.</div>Doug The Unahttp://www.blogger.com/profile/04753071669562594194noreply@blogger.com4tag:blogger.com,1999:blog-7400857.post-73041477190087190532010-03-19T09:16:00.000-07:002010-03-19T09:48:05.423-07:00Because a new post is sorely neededI apologize to the few but loyal readers that not much has come to mind to write about here. There's big news about Lanterman Developmental Center, of course, a topic on which I don't feel qualified to opine about. <div><br /></div><div>But, in the post below, <a href="http://en.wikipedia.org/wiki/Godwin%27s_law">Godwin's Law</a> seems to have reproven itself and the phrase "dead white male philosophers" has also appeared and I feel ready to propose my own <i>Doug's First Law of Internet Discourse:</i> To wit, no subject is so arcane that common platitudes won't dominate the discussion once the topic has been exhausted. </div><div><br /></div><div>So, lacking anything else to mind, I'll open the thread to you all with three questions:</div><div><b><span class="Apple-style-span" style="color:#000066;">First</span></b>, if anyone out there has interacted with the Delatorre audit, I'd be interested in hearing about the tone and rigor of the inquiry. Can anyone tell how well-informed the study has been or whether it appears vindictive or exploratory?</div><div><br /></div><div><span class="Apple-style-span" style="color:#000066;"><b>Second</b></span>, if self-determination/directed-services is no longer an available option for streamlining and improving the system, what would you all suggest as a conceptual frame for intentional systemic reform?</div><div><br /></div><div><b><span class="Apple-style-span" style="color:#000066;">Third</span></b>, an anonymous guest suggested something I absolutely agree with (and have agreed with in previous posts,) that more funding won't fix a broken system. Anonymous suggests Stanley's answer to the question, but I am curious for two sentence answers: Do you all think the system is primarily underfunded or primarily broken? </div><div><br /></div><div>Some etiquette: Let's start by answering one of the three questions (as opposed to two, all or none) per comment, begin by identifying which question you are answering and, if at all possible, consider the poor blogger who feels compelled to read all the comments and try to begin with two- or three-sentence replies.</div><div><br /></div><div>I'll try to come up with a new post before anyone begins comparing department directors to war criminals.</div>Doug The Unahttp://www.blogger.com/profile/04753071669562594194noreply@blogger.com27tag:blogger.com,1999:blog-7400857.post-56494393626394740662010-01-29T10:42:00.000-08:002010-01-29T11:03:58.139-08:00Who will reward the far-seeing?<div style="text-align: justify;">OK, so <a href="http://arribails.blogspot.com/2009/12/looking-forward-to-2010.html">this post</a> was either not prescient or very prescient. I doubt we're done with cutting.</div><div style="text-align: justify;"><br /></div><div><div style="text-align: justify;">So, here's a topic for discussion. Immanuel Kant distinguished between phenomena, things that are observed, and noumena, things as they are in themselves. One thing I believe strongly about our system (and most others) is that the phenomena we describe when we talk about support to people with developmental disabilities, are almost entirely process. That makes sense, considering that support is initially a verb. But process is hard to defend and, really, if all we do is do, and nobody gets anything of value in itself, then it may be right that we have trouble defending. My question, regarding what our system produces, is what do you all think the noumenon is? What is the thing in itself that people with disabilities receive from all the work that goes on.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">Just to handicap the discussion, "dignity," "sovereignty," "choice" or "safety" sound too abstract to me. Is there something people get from being supported that they would know they lacked if the system went away? What are those things?</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">So how is everybody?</div></div>Doug The Unahttp://www.blogger.com/profile/04753071669562594194noreply@blogger.com44tag:blogger.com,1999:blog-7400857.post-82572546867548161472009-12-30T06:57:00.000-08:002009-12-30T07:25:39.999-08:00Looking forward to 2010<div style="text-align: justify;">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:</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">If the cuts proposed have been (tragic but) thoughtful:</div><div><ol><li style="text-align: justify;">Rates will compress toward the low end, not fall by a fixed percentage.</li><li style="text-align: justify;">In explaining the cuts, resistance by large lobbying organizations won't be mentioned.</li><li style="text-align: justify;">Those will be least affected who are most urgently in need.</li><li style="text-align: justify;">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.</li><li style="text-align: justify;">Andy Pereira will need to think a short while before ranting.</li><li style="text-align: justify;">Some non-residential agencies may actually close.</li><li style="text-align: justify;">Contrary to the "furthest from the client" meme, the scope of support will narrow more than oversight fades.</li><li style="text-align: justify;">Many members of the cost-cutting stakeholder group will complain that they weren't listened to and mean it this time.</li><li style="text-align: justify;">The interdisciplinary team (IDT) approach, Individual Program Plan (IPP) primacy and fair hearing rights will be strengthened.</li><li style="text-align: justify;">The limits on the IDT and IPP will be clarified, in terms of requiring a clinical and practical rationale for support.</li></ol><div style="text-align: justify;">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.)</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">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.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">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. </div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">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. </div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">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.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">Of course, this budget is bad enough that we just have all non-residential care proposed for elimination. In which case, dangit.</div></div>Doug The Unahttp://www.blogger.com/profile/04753071669562594194noreply@blogger.com9tag:blogger.com,1999:blog-7400857.post-68706789293199321712009-11-17T11:27:00.000-08:002009-11-23T13:45:10.221-08:00The (Draft) Ten Guiding Principles for the ICBM<div style="text-align: justify;">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.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><ul><li>Reduces overall state General Fund costs.</li><li>Increases fairness, equity, and transparency in the allocation of resources.</li><li>Accounts for geographical cost differences.</li><li>To the extent possible, relies on existing state data systems and assessment processes.</li><li>Accommodates individuals with exceptional or unique care needs and their associated purchase-of-service costs.</li><li>Easy and efficient to administer for consumers, families and regional center personnel.</li><li>Does not jeopardize individual's health, safety and/or well-being.</li><li>Does not impose any unfunded mandates on participants, providers or regional centers.</li><li>Promotes individuals' ability to achieve and maintain living arrangements and work in the least restrictive settings.</li><li>To the extent possible, can be implemented within existing resources.</li></ul><br /></div><div style="text-align: justify;">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. </div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">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.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">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.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b><i><span class="Apple-style-span" style="color:#990000;">**Addendum**</span></i></b></div><div style="text-align: justify;">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.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">Also, the fact that this is a <i>draft</i> 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.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;"><b><i><span class="Apple-style-span" style="color:#000066;">**Duodendum**</span></i></b></div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">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.</div>Doug The Unahttp://www.blogger.com/profile/04753071669562594194noreply@blogger.com22tag:blogger.com,1999:blog-7400857.post-88951960149790252742009-11-11T09:32:00.000-08:002009-11-11T09:39:00.607-08:00ICBM outgoingLast 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. <div><br /></div><div>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.</div>Doug The Unahttp://www.blogger.com/profile/04753071669562594194noreply@blogger.com2tag:blogger.com,1999:blog-7400857.post-80261017469040374382009-10-06T13:01:00.000-07:002009-10-07T09:46:26.980-07:00A fair hearing for fair hearings<div style="text-align: justify;">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 <i>never</i> 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.) </div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">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.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">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 <i>federal</i> (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.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">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. </div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">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. </div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">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.</div>Doug The Unahttp://www.blogger.com/profile/04753071669562594194noreply@blogger.com22tag:blogger.com,1999:blog-7400857.post-88217509776885644122009-09-03T19:09:00.001-07:002009-09-03T21:05:47.591-07:00Praise Where It's Due<div style="text-align: justify;">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.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">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.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">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.</div><div><br /></div><div style="text-align: justify;">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.</div><div style="text-align: justify;"><br /></div><div style="text-align: justify;">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.</div><object width="425" height="344"><param name="movie" value="http://www.youtube.com/v/sevR8qpb9e0&hl=en&fs=1&"><param name="allowFullScreen" value="true"><param name="allowscriptaccess" value="always"><embed src="http://www.youtube.com/v/sevR8qpb9e0&hl=en&fs=1&" type="application/x-shockwave-flash" allowscriptaccess="always" allowfullscreen="true" width="425" height="344"></embed></object>Doug The Unahttp://www.blogger.com/profile/04753071669562594194noreply@blogger.com22