About the Examiner

So, 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.

***

Welcome,

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.

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.

About me: 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.

There is a phrase in the paragraph just above to make anyone skeptical, so here are the biases I'll admit to up front-

1. 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.
2. 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.
3. 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.
4. 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.
5. I am a reformer, may heaven have pity and my neighbors patience.

Sounds fun, right? I welcome your comments.

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:

Entitled to what?

Paul, maskless, brings up a very good point in the comments for the aging post below.  He states "Since I have found wide and interesting interpretations of the Lanterman Act I want to start where I hope we can agree. Client or families [SIC] goals are not implicit entitlements under the Lanterman Act."

I'm inclined to agree.  One of the challenges to the present system and any future better one is distinguishing between the outcomes of support and the results that are in the control of the end user.  It is fairly clear and I suspect uncontroversial that the entitlement is to service and support for the purpose of moderating the affects of developmental disabilities on the lives (goals) of the individuals served.  I might argue the proper outcome measurement for a service provider or regional center is a process measurement for the end user.  The quality support may not have to result in a person with disabilities experiencing success, but in their succeeding or failing the same way a person without disabilities would.

And yet, much disenchantment is with the event that people with disabilities are still unhappy and/or unfulfilled after receiving services.  Here lies one of the problems with using client satisfaction as an outcome.  Another lies in the fact that achievers are rarely satisfied.

I'd be interested to hear your thoughts.  Especially yours, Stanley, you old crank.

Incidentally, Monday marked the fourth anniversary of this blog even if I didn't.  Thanks to all of you have joined the conversation over that time.

Families and Reform

The Apostle Stanley is stirring it up in the comments in the post below this one, comforting the afflicted and afflicting the rational.  His comments have inspired some thought on my part, no mean accomplishment.  

If you look through this blog over the years, those reforms I argue for most consistently: transparent and public outcome evaluations of programs and policies, self-determination and its pale cousin self-directed services and value-stream management share a common assumption: That end users of the system, given the means and opportunity to do so, will choose quality supports providing the maximum likelihood of achieving the client or families goals.  It is on this basis as well, that I tend to kick against top-down, regimentary solutions such as those Stanley suggests.

I make this assumption in direct contradiction to some experiences I've had.  I am often at meetings with groups of clients and/or family-members gathered for the purpose of advocacy.  Often at those meetings, complaints are rife towards service providers and regional centers.  The commonest answer to "have you discussed this with your agency/regional center?" seems to be "I am afraid they will retaliate."  The commonest response to "Have you considered changing agencies/service coordinators?" seems to be "It's a lot of work and, anyway, the next one might be worse than the last." 

I recently told a good friend after one such meeting of my suspicion that if mediocrity in a service provider cost money, excellence would abound.  Likewise, I suspect that if listless service coordination made extra work, service coordinators would struggle to be responsive.  

I am sure fears of retaliation aren't entirely unjustified and I certainly grant (and assert) that discovering quality supports is impractically hard.  But, if end users won't seek alternatives to poor service, then Stanley is probably right, the only way this system will get any better is a top-down process that will also make it less creative, innovative and diverse.

Whose quality?

Inspired by Brer Stanley, our new topic for debate is about quality.  Quality is something we all agree is important and then, by and large, ignore.  People who have read this blog in the past know that the opinion here is that the single most important reform we could make to our system is ongoing evaluation of the quality of programs, regional centers and policies on the basis of outcomes.  Here's the tricky part:  We just debated whether choice is or is not more important than integration.  If it is, there's a challenge to the measurement of quality.  It is very hard to standardize the evaluation of choice because standard measures need to be valid , meaning that the metric must measure what is designed to measure and be counted the same way by different surveyors.  So the challenge will be developing valid metrics to gather statewide while honoring choice.

One model, the one used by HSRI, for instance, I think, is fairly strong on validity but weak on choice.  Even if you evaluate based on whether a client reports being given a choice, if every other metric assumes the state's preferred outcome and rewards for it, the pressure is to treat all people with developmental disabilities as if their most intimate decisions are to be pleasing to the people at the Bateson Building in Sacramento.  

The common alternative model, I think of it as the JN or LQA model, is to have a deeply considerate and subjective evaluation so cumbersome it typically sits on someone's shelf unimplemented.  

A typical Life Quality Assessment was kind of silly because it was so subjective that which day of the week a client was interviewed could alter the entire result.  A more valid survey biases every professional in a client's life toward state policy and away from the person served.

So, the question to you all is: Is it better to employ a highly valid system that might counteract client choice or is it better to use a subjective system which honors choice at the expense of usefulness or is there a better or more balanced solution?